Urinary Tract Infections in Male Veterans with HIV

Background: In an era of increased antimicrobial resistance and widespread Clostridium difficile infection (CDI), improving antimicrobial stewardship and optimizing treatment duration are increasingly important. Recent literature suggests that longer-duration therapy for men with urinary tract infections (UTIs) is associated with no benefit, but with some harm. Whether this holds true for men infected with Human Immunodeficiency Virus (HIV) is unknown. Furthermore, patterns of UTI treatment in such men are poorly described. We used Veterans Affairs (VA) administrative data to describe UTI treatment in a cohort of HIV-positive men, and compared treatment patterns and outcomes to men without HIV who were treated for UTI.

Methods: Fiscal Year 2009 VA data were used to identify male UTI episodes by identifying International Classification of Diseases, Ninth Revision codes associated with UTI-relevant antimicrobial prescriptions. Descriptive statistics were used to compare treatment patterns and outcomes. Continuous variables were compared using t-tests, whereas categorical variables were compared using chi-square tests. We also tested for interactions between trimethoprim-sulfamethoxazole (TMP-SMZ) use and treatment patterns and between TMP-SMZ use and outcomes.

Results: Among 33,336 veterans with UTI, 234 had a diagnosis of HIV. The most frequently used antimicrobials in patients with HIV were fluoroquinolones (70.5%), TMP-SMZ (18.0%), and beta-lactams (7.3%). Drug selection and relative frequency were similar for UTI episodes in men without HIV. Patients with HIV had no increase in recurrence (either within 30 days, or later) relative to men without HIV. However, CDI following UTI treatment was more common in patients with HIV, vs. without HIV (1.3% vs. 0.4%: P = 0.047).

Conclusion: In the VA, men with HIV are treated similarly to men without HIV for UTI, and appear to be at no increased risk of recurrence. There was a three-fold increase in the rate of CDI in patients with HIV; whether this is secondary to UTI therapy or the fact that they are sometimes on long term antimicrobials for prophylactic reasons, is unknown.