Tools for Practice


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


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

BOTTOM LINE
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
  • 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%).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

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Author(s):

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

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.