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

Reading Tools for Practice Article can earn you MainPro+ Credits
Join NowAlready a CFPCLearn Member? Log in
- 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
- 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.
- 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.
- 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.
- 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.
- 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.
- ≥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