Tools for Practice Outils pour la pratique

#327 To Treat or Not Treat Uncomplicated UTIs

Do we need to use antibiotics to treat uncomplicated symptomatic urinary tract infections (UTI)?

About two-thirds of non-pregnant adult women with uncomplicated symptomatic UTI will have persistent symptoms without treatment. At 3-4 days, 46% of women treated symptomatically with NSAIDs alone will be symptom-free versus 67% given antibiotics. By one month, fever and/or pyelonephritis developed in 1.2% given NSAIDs alone versus 0.2% given antibiotics. Women with uncomplicated symptomatic UTI should be offered antibiotics.

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  • Results statistically significant unless indicated.
  • Systematic review (3 Randomized Controlled Trials [RCT], 346 non-pregnant women) focusing on patients given placebo.1
    • Symptom-free at 4-7 days: Approximately 31% without antibiotics (range 28%-60%) (PEER pooled data for average).
    • Symptom-free at 6 weeks: 36% without antibiotics.
    • Adverse events: No consistent difference. 2 untreated patients progressed to pyelonephritis (versus 1 treated with antibiotics).
  • Systematic review (4 RCTs, 1165 non-pregnant women) randomized to symptomatic treatment with NSAIDs (ibuprofen or diclofenac) versus antibiotics (ciprofloxacin, fosfomycin, norfloxacin, or pivmecillinam).2
    • Symptom-free at 3-4 days: NSAIDs lower (46%) versus antibiotics (67%), number needed to harm (NNH)=5 for using NSAIDs versus antibiotics.2
    • Adverse events (fever or pyelonephritis at ≤1 month): NSAID higher (1.2%) than antibiotics (0.2%), NNH=100 for using NSAIDs versus antibiotics.2
    • Other systematic review found similar.3
  • Uncomplicated UTI is generally defined as adult (age 18-65) non-pregnant women with symptoms of cystitis with normal urinary tracts and immune systems.3,4
    • Asymptomatic bacteriuria is different and will be covered in future Tools for Practice.
  • Women presenting to primary care concerned about uncomplicated UTI have a high prevalence (>60%) of UTI; history and dipstick testing are generally of limited value.5
  • Empiric antibiotics maybe reasonable for uncomplicated UTI.
    • RCT, 309 non-pregnant women presenting to primary care with uncomplicated UTI were randomized to one of five antibiotic treatment options: Immediate, if dipstick positive, ≥2 symptoms, delayed for persistent symptoms, or if culture positive. All approaches provided similar symptom control.6
    • RCT of 59 non-pregnant women with uncomplicated UTI symptoms and negative dipstick urinalysis randomized to antibiotics or placebo found less dysuria after day 3 on antibiotics (24%) versus placebo (74%).7

Peter Wells November 14, 2022

Nice to confirm current practice

Peter Wells November 14, 2022

Confirms current practice

Bilkis Humama November 14, 2022

Confirm current practice

Donna Mahoney November 15, 2022

Will continue as is, then! Thanks!

sadia tahir November 16, 2022

confirm current practice

Andrew Affleck November 18, 2022

Confirms present practice

Andrew Affleck November 18, 2022

Makes sense

peter entwistle November 19, 2022

mmm – interesting way of presenting findings.
there are immediate patient harms and societal harms of using antibiotics for uncomplicated uti – surely a patient centred conversation 1in 5 chance they help and 1 100 chance will prevent some bad infection but antibiotics roughly have 1in 8 chance of causing harms

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  • G. Michael Allan MD CCFP
  • Betsy Thomas BSc. Pharm
  • Jennifer Young MD CCFP-EM

1. Hoffmann T, Peiris R, Mar CD, et al. Br J Gen Pract. 2020; 70(699):e714-e22.

2. Ong Lopez AMC, Tan CJL, Yabon AS 2nd, et al. BMC Infect Dis. 2021; 21(1):619.

3. Carey MR, Vaughn VM, Mann J, et al. J Gen Intern Med. 2020; 35(6):1821-9.

4. Bent S, Nallamothu BK, Simel DL, et al. JAMA. 2002; 287(20):2701-10.

5. Young J, Thomas B, Allan GM. Tools for Practice, College of Family Physicians of Canada, 2022 October 3. #324. [Accessed October 28, 2022]

6. Little P, Moore MV, Turner S, et al. BMJ. 2010 Feb 5; 340:c199. doi: 10.1136/bmj.c199.

7. Richards D, Toop L, Chamber S, et al. BMJ, doi:10.1136/bmj.38496.452581.8F (published 22 June 2005)

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.