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OBJECTIVE We aimed to determine the clinical impact of inappropriate empirical antibiotic treatment (IEAT) compared with appropriate empirical antibiotic treatment (AEAT) in hospitalised patients with urinary tract infections (UTIs) caused by Escherichia coli (E. coli). METHODS This retrospective cohort study included adult patients with a primary diagnosis of UTI who were treated with empirical antibiotics at a tertiary hospital in southern China over a 2-year period. The clinical data of patients who received IEAT were compared with those of the patients receiving AEAT. We used multivariable logistic regression to identify the predictors for receiving IEAT and the risk factors affecting the clinical outcomes. RESULTS Two hundred and thirteen patients were enrolled (median age, 61 years). Of these patients, 103 (48.4%) received IEAT. IEAT was associated with the empirical use of fluoroquinolones, male sex, and age-adjusted Charlson comorbidity index (aCCI) score >6. The length of stay (LOS) was longer for patients who received IEAT than for those who received AEAT (13.6 ± 8.6 d vs 10.8 ± 7.9 d; P = 0.008). IEAT was an independent risk factor for longer LOS along with aCCI score ≥2, lung disease and cardiac disease. CONCLUSION Empirical use of fluoroquinolones for UTIs should be avoided, especially in male patients with aCCI score >6. Improved empirical antimicrobial therapy may have a beneficial impact on reducing bacterial resistance and health-care costs by decreasing the LOS. Therefore, interventions to promote in-depth antibiotic stewardship programmers in China are needed.