Can antibiotics be discontinued in a patient with a history of multidrug-resistant organism (MDRO) infection, admitted for a complicated urinary tract infection (UTI) with a negative urine culture?

Discontinuing Antibiotics in a Patient with MDRO History and Negative Urine Culture

Antibiotics should be discontinued in a patient with a history of multidrug-resistant organism (MDRO) infection who was admitted for a complicated UTI but has a negative urine culture.

Rationale for Discontinuation

The decision to discontinue antibiotics is supported by current guidelines and evidence-based practice:

• A negative urine culture in a patient admitted for a complicated UTI provides objective evidence that there is no active bacterial infection requiring antimicrobial treatment 1.

• The European Association of Urology (EAU) guidelines emphasize that urine culture and susceptibility testing should be performed before initiating empiric therapy for complicated UTIs, and therapy should be tailored based on culture results 1.

• Continuing antibiotics despite negative cultures contributes to antimicrobial resistance development, which is particularly concerning in patients with a history of MDRO infections 1.

Management Algorithm

1. Confirm negative culture result:

   • Ensure the urine sample was properly collected
   • Verify no antibiotics were administered before sample collection
   • Check if the culture was processed appropriately

2. Assess clinical status:

   • If patient is clinically improving or stable: Discontinue antibiotics
   • If patient remains symptomatic despite negative culture:
     • Consider alternative diagnoses
     • Evaluate for non-infectious causes of symptoms
     • Consider repeat urine culture if initial sample was collected while on antibiotics

3. Special considerations for patients with MDRO history:

   • Monitor closely after antibiotic discontinuation
   • Document MDRO history clearly in medical record for future reference
   • Consider infectious disease consultation if clinical picture remains unclear

Antimicrobial Stewardship Principles

The decision to discontinue antibiotics aligns with antimicrobial stewardship principles:

• Avoiding unnecessary antibiotic use helps prevent further development of resistance, particularly important in patients with prior MDRO infections 1.

• The American Urological Association guidelines specifically recommend against treating asymptomatic bacteriuria in patients with neurogenic lower urinary tract dysfunction, emphasizing the importance of antibiotic stewardship 1.

• Even in complicated UTIs, treatment should be guided by culture results rather than empiric therapy alone 1.

Common Pitfalls to Avoid

• Continuing empiric therapy despite negative cultures: This practice contributes to antimicrobial resistance and exposes patients to unnecessary medication risks.

• Misinterpreting persistent symptoms: Not all urinary symptoms indicate infection; consider non-infectious causes such as urinary retention, stones, or inflammation.

• Inadequate follow-up: After discontinuing antibiotics, ensure appropriate follow-up to monitor for symptom recurrence or clinical deterioration.

• Failure to document MDRO history: Ensure proper documentation of the patient's MDRO history to guide future empiric therapy if needed.

By following these evidence-based recommendations, clinicians can provide appropriate care while practicing responsible antimicrobial stewardship, ultimately improving patient outcomes and reducing the risk of further antimicrobial resistance development.