Tools for Practice


#327 To Treat or Not Treat Uncomplicated UTIs


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

BOTTOM LINE
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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EVIDENCE
  • 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
Context
  • 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
November 13, 2022

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Author(s):

  • Betsy Thomas BSc. Pharm
  • G. Michael Allan MD CCFP
  • 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. https://gomainpro.ca/wp-content/uploads/tools-for-practice/1664574685_tfp324_dxuti.pdf [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.