Cephalosporins for Outpatient Pyelonephritis in the Emergency Department: COPY-ED Study

Jenny Koehl; Devin Spolsdoff; Briana Negaard; Alison Lewis; Ruben Santiago; James Krenz; Alyssa Polotti; Ryan Feldman; Giles Slocum; David Zimmerman; Gavin T Howington; Preeyaporn Sarangarm; Alicia E Mattson; Caitlin Brown; Anne Zepeski; Megan A Rech; Brett Faine

doi:10.1016/j.annemergmed.2024.10.013

Cephalosporins for Outpatient Pyelonephritis in the Emergency Department: COPY-ED Study

Ann Emerg Med. 2024 Nov 19:S0196-0644(24)01140-5. doi: 10.1016/j.annemergmed.2024.10.013. Online ahead of print.

Authors

Jenny Koehl¹, Devin Spolsdoff², Briana Negaard³, Alison Lewis³, Ruben Santiago⁴, James Krenz⁴, Alyssa Polotti⁵, Ryan Feldman⁶, Giles Slocum⁷, David Zimmerman⁸, Gavin T Howington⁹, Preeyaporn Sarangarm¹⁰, Alicia E Mattson¹¹, Caitlin Brown¹¹, Anne Zepeski¹², Megan A Rech¹³, Brett Faine¹⁴

Affiliations

¹ Department of Emergency Medicine and Pharmacy, Massachusetts General Hospital, Boston, MA.
² Department of Emergency Medicine, University of Iowa, Iowa City, IA.
³ Department of Pharmacy, Indiana University Health, Academic Health Center, Indianapolis, IN.
⁴ Department of Pharmacy, Jackson Memorial Hospital, Miami, FL.
⁵ Department of Pharmacy, St. Mary Medical Center - Trinity Health, Langhorne, PA.
⁶ Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Milwaukee, WI.
⁷ Department of Pharmacy and Emergency Medicine, Rush University Medical Center, Chicago, IL.
⁸ Department of Pharmacy; Duquesne University School of Pharmacy; Pittsburgh, PA.
⁹ Department of Pharmacy Practice and Science, University of Kentucky, Pharmacy Services, University of Kentucky HealthCare, Lexington, KY.
¹⁰ Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM.
¹¹ Department of Pharmacy and Emergency Medicine, Mayo Clinic, Rochester, MN.
¹² Department of Emergency Medicine and Pharmacy, University of Iowa, Iowa City, IA.
¹³ Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, IL.
¹⁴ Department of Emergency Medicine and Pharmacy, University of Iowa, Iowa City, IA. Electronic address: brett-faine@uiowa.edu.

PMID: 39570254
DOI: 10.1016/j.annemergmed.2024.10.013

Abstract

Study objective: The primary objective of our study was to compare the effectiveness of oral cephalosporins versus fluroquinolones and trimethoprim/sulfamethoxazole (TMP-SMX) for the treatment of pyelonephritis in patients discharged home from the emergency department (ED).

Methods: This was a multicenter, retrospective, observational cohort study of 11 geographically diverse US EDs. Patients aged ≥18 years diagnosed with pyelonephritis and discharged home from the ED between January 1, 2021 and October 31, 2023 were included. The primary outcome was treatment failure at 14 days defined as a composite outcome of the following: (1) recurrence of urinary symptoms, (2) repeat ED visit or hospitalization for a urinary tract infection, (3) receipt of a new antibiotic prescription for urinary tract infection. Secondary outcome was appropriateness of empiric treatment based on urine culture susceptibility.

Results: Among the 851 patients who met inclusion criteria, 647 patients received a cephalosporin, and 204 patients received an Infectious Diseases Society of America guideline-endorsed first-line treatment (fluroquinolones, TMP-SMX). Overall, baseline characteristics were similar between the 2 cohorts. Rates of treatment failure were not significantly different in the cephalosporin group compared with the fluroquinolone/TMP-SMX groups (17.2% of cephalosporin vs 22.5% of fluroquinolone/TMP-SMX group, difference=5.3%, 95% confidence interval -0.118 to 0.01). After adjusting for potential confounders, cephalosporin use was not associated with treatment failure (odds ratio=0.22, 95% confidence interval 0.03 to 1.95). There was no difference in rates of appropriate empiric treatment based on urine culture susceptibility.

Conclusion: Oral cephalosporins were associated with similar treatment failure rates compared with Infectious Diseases Society of America guideline-endorsed treatments for the treatment of pyelonephritis in ED patients discharged home.