Tools for Practice Outils pour la pratique


#337 Clear, not cloudy: Antibiotic options for uncomplicated urinary tract infections


CLINICAL QUESTION
QUESTION CLINIQUE
What is the preferred treatment regimen for uncomplicated Urinary Tract Infections (UTI)?


BOTTOM LINE
RÉSULTAT FINAL
For symptom resolution, all antibiotics are similar. Based on limited evidence, best guidance for treatment durations for symptom resolution are nitrofurantoin 5-day; trimethoprim-sulfamethoxazole, beta-lactams, ciprofloxacin and norfloxacin 3-day, and fosfomycin 1-day. Treatment choice should be driven by patient preference, local resistance, side effects, and allergies.



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EVIDENCE
DONNÉES PROBANTES
  • Results statistically significant unless indicated.
  • Antibiotic choice:
    • Six systematic reviews1-6 (4-27 RCTs, 1497-6016 mostly adult women) compared different antibiotics (beta-lactams, fluoroquinolones, fosfomycin, nitrofurantoin, and trimethoprim-sulfamethoxazole) for UTI symptoms and/or positive urine culture.
      • Symptom resolution: No difference between antibiotics.1-6
      • Bacterial eradication at ≤2 weeks: Fluoroquinolones4,6 (88-89%) superior to nitrofurantoin4 (79%) and beta-lactams6 (70%); no difference at 4-8 weeks.6
      • Adverse effects: Less rash with nitrofurantoin (0.2%) and fluoroquinolones (0.1%) versus trimethoprim-sulfamethoxazole (2.6%) and beta-lactams (6%).
  • Duration:
    • Systematic review7 (32 RCTs, 9605 women, 16-65 years old) comparing 3-days versus 5-10 days of the same antibiotic. Antibiotics included beta-lactams, fluoroquinolones, cephalosporins, sulfonamides and trimethoprim-sulfamethoxazole at typical doses.
      • Symptom resolution: No difference.
      • Bacterial eradication with 3-day versus ≥5-day at <2 weeks (91% versus 93%) and 4-8 weeks (82% versus 87%), respectively.
    • Network meta-analysis8 (61 RCTs, 20,780 women) compared treatment durations. Direct comparisons for clinical response reported below.
      • Symptom resolution: Fluoroquinolones: 1 or 3-days similar except second-generation (example ciprofloxacin, norfloxacin) may be slightly (~5% relatively) more effective at 3-days. Third and fourth generation fluoroquinolones studied are not available in Canada.
      • Other data agrees with first systematic review.7
      • Data lacking for nitrofurantoin.
  • Fosfomycin is single dose in all studies.1-3,5
  • Limitations: Older studies with low quality evidence. Few direct comparisons between different durations of antibiotics.
Context
  • ≥60% of women in primary care presenting with suspected UTI have one.9
  • Small differences in bacterial eradication rates don’t appear to impact clinical symptoms and may be irrelevant.
  • Guidelines10,11 recommend nitrofurantoin 5-day (~$21), trimethoprim-sulfamethoxazole 3-day (~$14) and fosfomycin 1-day as first-line treatment (~$33).12
  • Updated resistance patterns found at provincial antibiograms.13-14


RUBY NG April 3, 2023

I can treat UTI with Nitorfurantoin for 5 days instead of 7 days

Sayema Parveen April 3, 2023

good resource for choosing antibiotic for UTI

Andrew Whynot April 3, 2023

thanks

Azim Jiwani April 3, 2023

I find higher rates of recurrent symptoms with fosfomycin

Ingrid Harle April 3, 2023

Good summary

DIANE ROTHON April 3, 2023

Very good article.

Bonnie Madonik April 4, 2023

good suggestions

Shelagh Leahey April 4, 2023

Shocking that it is so simple and effective for both pt and MD to effectively cure uncomplicated UTI

David Wood April 7, 2023

confirmed present practice

Anna Roebuck April 8, 2023

very relevant, clear and concise advice- useful

Dr ARUP KUMAR DHARA April 13, 2023

Excellent

Gilbert Bretecher May 10, 2023

5 day Nitrofurantoin very effective


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Author(s)
Auteur(s)
  • Jennifer Young MD CCFP-EM
  • Betsy Thomas BSc. Pharm
  • G. Michael Allan MD CCFP

1. Alfaresi M, Hassan K and Alnjadat R, et al. Open Microbiology Journal. 2019; 13:193-199.

2. Cai T, Tamanini I, Tascini, C et al. J Urology. 2020; 203(3):570-578.

3. Falagas M, Vouloumanou E Togias A et al. J Antimicrob Chemother. 2010; 65:1862–1877.

4. Huttner A, Verhaigh E, Harbarth S et al. J Antimicrob Chemother 2015; 70:2456–2464.

5. Konwar M, Gogtay N, Ravi R et al. J Chemother. 34:3,139-148

6. Trestioreanu Z, Green H, Paul M et al. Cochrane Database Syst Rev. 2010 (10): CD007182.

7. Milo G, Katchman EA, Paul M, et al. Cochrane Database Syst Rev. 2005 Apr 18; (2):CD004682.

8. Kim D, Kim J, Lee J et al. Lancet Infect Dis 2020; 20:1080–88.

9. Young J, Thomas B, Allan M. Tools for Practice #324. Available at https://cfpclearn.ca/tfp324/. Accessed on Feb 17, 2023.

10. Ontario Anti-infective Review Panel. 2019. Anti-infective Guidelines for Community-acquired Infections. Toronto, Ontario, Canada: MUMS Health Clearinghouse.

11. Bugs and Drugs. Available at: https://www.bugsanddrugs.org/7399B374-C9F6-4044-9E03-86B1D11F2874. Accessed on February 17, 2023.

12. Personal communication with Summerside Pharmacy, Edmonton, Alberta, Dec 7, 2022.

13. British Columbia, Saskatchewan, and Ontario antibiograms. Available at: https://www.lifelabs.com/healthcare-providers/reports/antibiograms/. Accessed on February 17, 2023.

14. Alberta Antibiograms. Available at: https://www.albertaprecisionlabs.ca/hp/Page13779.aspx. Accessed on February 17, 2023.

Authors do not have any conflicts of interest to declare.

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