2025 Southeastern Residency Conference

Title: EVALUATION OF EMPIRIC ANTIBIOTICS IN SEPSIS VERSUS NON-SEPSIS UTI PATIENTS


Authors: Marquist Henderson, Megan Heath, Doug Carroll


Objective: Discuss the appropriate empiric antibiotic treatment for urinary tract infections and sepsis based on current guidelines and evidence-based literature. 


Self Assessment Question: What is an appropriate empiric agent for a patient with sepsis and MRSA risk factors?


Background: UTIs are among the most common infections in the community and inpatient settings. As noted in the IDSA 2011 guidelines for treating uncomplicated cystitis and pyelonephritis, when selecting an antibiotic, it is essential to consider patient-specific factors, the severity of the infection, and the inpatient facility’s local antibiogram. However, since the IDSA guidelines have not been updated since 2011, UpToDate has reviewed literature with updated topics and guidance called “Acute complicated urinary tract infection (including pyelonephritis) in adults and adolescents,” which may be more applicable to clinicians in today’s current environment. 
If left untreated, UTIs can lead to sepsis. The Surviving Sepsis 2021 Campaign guidelines recommend that antimicrobials should be started within one hour when there is a high suspicion of sepsis or septic shock. However, the guidelines do not specify which antimicrobials should be used; instead, clinicians should utilize clinical judgment to decide on appropriate empiric antibiotics based on patient's risk factors and suspected source of infection. This project was completed to evaluate our management of patients with UTI that present with sepsis compared to those without sepsis. 




Methods: A list of patients admitted to the DCH Regional Medical Center from January 1, 2024, to August 31, 2024, was generated from the electronic health record with positive urine cultures and either an ICD-10 code for a urinary tract infection (cystitis and pyelonephritis) or an ICD-10 code for sepsis.  Patients were excluded if they were diagnosed with septic shock or had multiple sources of infection. Each patient was randomly stratified into the UTI cohort or UTI with sepsis cohort and reviewed until 75 patients were in each group. The primary outcome was determined by the appropriateness of empiric antibiotic therapy administered within the first 3 hours of admission. Appropriateness of therapy was determined by risk factors in stated in the UpToDate and Surviving Sepsis 2021 Campaign guidelines. The secondary outcomes collected were comparing the pathogens isolated from the culture results, incidences of MDROs, overbroad empiric therapy, and rates of bug-drug mismatch between each group. 
 
Results: In the sepsis cohort, 40% were treated appropriately per the guideline recommendations, and in the non-sepsis cohort, 78% were treated appropriately. E. Coli was the most common pathogen isolated from both sepsis and non-sepsis groups, 59% and 41.3%, respectively. In the sepsis cohort, there were 8 MDRO pathogens isolated, while there were 9 MDRO pathogens isolated in the non-sepsis cohort. In the sepsis cohort, 27.3% patients were treated with overbroad therapy, and 18.7% had a bug-drug mismatch. In the non-sepsis cohort, 5.3% were treated with over-broad therapy, and 30.7% had a bug-drug mismatch.


Conclusion: There was a lower percentage of patients treated appropriately in the sepsis cohort due to risk factors that warranted exteneded coverage or receiving extended coverage without any risk factors. In addition, more patients were treated appropriately per guideline recommendations in the non-sepsis cohort versus the non-sepsis, there were higher rates of bug-drug mismatch in this cohort. There is an opportunity for educating providers on assessing risk factors for broader coverage when treating a UTI.