Reference – BMJ 2015 Dec 23;351:h6544 (level 1 [likely reliable] evidence)
- Immediate antibiotic therapy is currently recommended for women with uncomplicated urinary tract infections (UTI), although a portion of these infections may be self-limited.
- In women not immediately treated with antibiotics, 65% had symptom resolution with ibuprofen alone and 35% required antibiotic treatment.
- The time to symptom resolution was significantly longer with ibuprofen.
Increasing rates of antibiotic resistance have strengthened the need for judicious antibiotic use and antimicrobial stewardship. Current recommendations support immediate antibiotic therapy for uncomplicated urinary tract infections (UTIs) (Clin Infect Dis 2011 Mar 1;52(5):e103, EAU 2015 Mar PDF), even though some data suggests that many uncomplicated UTIs are self-limited (Curr Infect Dis Rep 2013 Apr;15(2):124). To assess the potential to treat UTI symptoms without antibiotics, a recent randomized trial compared ibuprofen 400 mg 3 times daily vs. single dose fosfomycin 3 g in 494 women aged 18-65 years with symptoms of uncomplicated UTI. UTI symptoms considered for trial inclusion were dysuria or frequency/urgency of micturition, with or without lower abdominal pain. Women were excluded for symptoms of upper urinary tract infection including fever or loin tenderness. Both groups received placebo pills for the corresponding active treatment given to the other group to maintain blinding. Urine cultures and dipstick tests were performed, but the results did not inform eligibility. All women were advised to consult their general practitioner if symptoms persisted or worsened, at which point antibiotic treatment was prescribed at the discretion of the practitioner based on the initial urine culture results.
Ten women were incorrectly screened and excluded from the trial after randomization. Among the 484 women included in the intention-to-treat analysis, 92% (446 women) completed the 28 day follow-up. Urine culture results were available for 471 women, with a positive urine culture (> 100 colony forming units/mL) in 76% (360 women). Comparing ibuprofen vs. fosfomycin at day 28, antibiotics were prescribed to 35% vs. 100% (p < 0.001). The total number of antibiotic courses prescribed within 28 days was 94 in the 222 women treated with ibuprofen vs. 283 in the 224 women treated with fosfomycin (p < 0.001). This corresponds to an overall 66.5% incidence rate reduction in antibiotic use in the ibuprofen group. In a subgroup analysis of women with a positive urine culture, ibuprofen was associated with a 58.5% reduction in antibiotic use. However, ibuprofen was associated with an increased time to symptom resolution. Only 39% of women treated with ibuprofen had symptom resolution at day 4 compared to 56% treated with fosfomycin (p < 0.001). At day 7, symptom resolution occurred in 70% with ibuprofen vs. 82% with fosfomycin (p = 0.004). Although there was no significant difference in symptom worsening within 7 days, there was a nonsignificant increase in the rate of pyelonephritis in the ibuprofen group (5 cases vs. 1 case).
In this trial, 65% of women with an uncomplicated UTI initially treated with ibuprofen recovered without antibiotic treatment. While treatment with ibuprofen was associated with an increased total symptom burden within the first 7 days, the mean duration of symptoms was only 1 day longer with ibuprofen compared to fosfomycin. The number of pyelonephritis cases was higher in women receiving ibuprofen, but the overall rate was low and the difference did not reach statistical significance. This potential for reducing antibiotic use is analogous to the current treatment of otitis media. For many children with nonsevere otitis media, the recommended approach is shared decision making with the parents regarding the choice between antibiotics or observation with close follow-up. The results of this trial suggest that for women with mild uncomplicated UTIs, it may be reasonable to counsel about the potential for infection resolution without antibiotics and give the option to forgo antibiotics unless symptoms persist or worsen. One option is to empower the patient by giving a prescription that can be filled at the patient’s discretion, which has been shown to reduce the use of antibiotics in patients presenting with respiratory tract infections.
For more information, please see the Uncomplicated urinary tract infection (UTI) (pyelonephritis and cystitis) topic in DynaMed Plus.