Symptomatic treatment for uncomplicated UTI reduced rate of antibiotic prescription

1. Uncomplicated urinary tract infections are a commonly encountered complaint and account for a significant proportion of antibiotic prescriptions.

2. This study randomized patients presenting with symptoms of uncomplicated urinary tract infection to symptomatic treatment with ibuprofen or fosfomycin.

3. The ibuprofen group received significantly fewer antibiotic prescriptions in the 28 days following randomization when compared with the fosfomycin group. Patients treated with ibuprofen experienced a significantly higher burden of symptoms compared to those treated with antibiotics.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Uncomplicated urinary tract infections are a commonly encountered complaint in clinical practice and account for a significant proportion of antibiotic prescriptions. These infections are often self-limiting, however, and previous trials have compared different approaches to managing uncomplicated urinary tract infections, including early antibiotic therapy, delayed antibiotic therapy, and placebo. Compared to early antibiotic administration, other approaches to management were linked with prolonged symptom duration, but no serious adverse effects. Given the concern regarding increasing antibiotic resistance, efforts are being made to limit antibiotic prescription where possible.

The Immediate versus Conditional treatment of Urinary Tract Infection (ICUTI) trial compared symptomatic management of urinary tract infections (i.e., ibuprofen) with fosfomycin therapy. Its findings demonstrated that symptomatically treated patients received significantly fewer courses of antibiotics compared with those treated with fosfomycin. Patients in the ibuprofen group, however, experienced a significantly higher burden of symptoms. While more cases of pyelonephritis developed in the ibuprofen group, this did not reach statistical significance. In summary, this study demonstrated that approximately two-thirds of women who present with symptoms of uncomplicated urinary tract infection will recover with symptomatic treatment alone and no antibiotics. Thus, initial symptomatic treatment with ibuprofen represents a potential approach to managing such infections.

Click to read the study in BMJ

Relevant Reading: Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial.

In-Depth [randomized controlled trial]: A total of of 494 patients from 42 general practice offices in Northern Germany were randomized as part of the study. In order to be eligible, patients had to be women, between 18 and 65 years of age, with typical symptoms of urinary tract infection (e.g., dysuria, frequency/urgency). Patients were excluded if they had signs of upper urinary tract infection (e.g., fever, flank pain), concurrent conditions like pregnancy or renal disease, recent urinary tract infection in the preceeding 2 weeks, and urinary catheters. Patients already taking non-steroidal anti-inflammatory drugs or antibiotics, and those with previous gastrointestinal ulcers were also excluded. Eligible patients were randomized to treatment with either ibuprofen 400 mg three times daily for three days or fosfomycin-trometamol 3 g once. The primary endpoints were the number of courses of antibiotics received in the 28 days following randomization (i.e., for any infection), and the burden of symptoms experienced, as measured by daily symptom scores from day 0 to day 7.

Patients in the ibuprofen group were prescribed significantly fewer courses of antibiotic therapy in the 28 days following randomization compared to those in the fosfomycin group (incidence rate reduction 66.5%; 95%CI 58.8-74.4%; p < 0.001). Women in the ibuprofen group, however, experienced significantly more symptoms compare to those treated with fosfomycin. There were 5 cases of pyelonephritis in the ibuprofen group and 1 in the fosfomycin group (p = 0.12).

Image: PD/CDC

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