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

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

Authors

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

Journal

Annals of Emergency Medicine, 2024

Conclusion

Oral cephalosporins are an effective alternative to guideline-recommended treatments (fluoroquinolones, TMP-SMX) for outpatient management of pyelonephritis in patients discharged from the ED. Treatment failure rates and culture-based appropriateness of empiric treatment were similar across groups.

Methods

• Design: Multicenter, retrospective, observational cohort study.
• Setting: 11 geographically diverse US EDs.
• Population:
• Adults aged ≥18 years diagnosed with pyelonephritis between January 2021 and October 2023.
• Excluded: Patients with complicated urinary tract infections, concurrent antibiotic use, or incomplete data.
• Intervention:
• Cephalosporins (e.g., cefdinir, cefpodoxime).
• First-line antibiotics per IDSA guidelines (fluoroquinolones, TMP-SMX).
• Outcomes:
• Primary: Treatment failure at 14 days, defined as:
1. Recurrence of urinary symptoms.
2. Repeat ED visit or hospitalization for UTI.
3. New antibiotic prescription for UTI.
• Secondary: Appropriateness of empiric treatment based on urine culture susceptibility.

Results

• Cohort Size:
• Total: 851 patients (647 cephalosporin; 204 fluoroquinolone/TMP-SMX).
• Treatment Failure Rates:
• Cephalosporins: 17.2%.
• Fluoroquinolones/TMP-SMX: 22.5%.
• Difference: 5.3% (95% CI -0.118 to 0.01, not significant).
• Adjusted Analysis:
• Cephalosporins were not significantly associated with treatment failure (OR=0.22, 95% CI 0.03 to 1.95).
• Appropriate Empiric Treatment:
• No significant difference in susceptibility between the two groups.