November 28, 2021

Shorter cycle of effective antibiotics for UTIs in men

Seven days of antibiotics was found to be as effective as 14 days in treating urinary tract infections (UTI) in men without fever, in a randomized controlled trial evaluating symptom resolution and follow-up for recurrence in patients aged 2 Veterans Affairs (VA) medical centers.

Dimitri Drekonja, MD, MS, Minneapolis VA Health Care System, Minnesota, and colleagues noted that UTIs are among the most common indications for antibiotics, and found that a study providing definitive evidence for non- inferiority of shorter treatments “has the potential to dramatically decrease antimicrobial use, particularly for agents active against gram-negative bacteria, in which emerging resistance is of great concern.”

In an accompanying editorial, Daniel Morgan, MD, MS and Karen Coffey, MD, MPH, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, point out that UTIs in men are traditionally treated for longer periods. than in women, often assuming it is necessary for an infection that develops despite the relative anatomical barrier of the longer male urethra.

Morgan and Coffey also note that although the Infectious Disease Society of America (IDSA) has guidelines for the treatment of uncomplicated urinary tract infections in women, there is no corresponding guideline for men, “in part to due to limited data “.

To contribute to these data, Drekonja and colleagues at the 2 VA sites randomized 272 participants diagnosed with UTI and treated with 7 days of ciprofloxacin or trimethoprim / sulfamethoxaxole to an additional 7 days of antibiotic or placebo. The investigators noted that agents such as amoxicillin-clavulanate is increasingly used in place of ciprofloxacin, but that patients were given the antibiotics commonly used in VA at the time of the study (d ‘April 2014 to December 2019 in Minneapolis and January 2018 to December 2019 in Houston).

All participants were ambulatory patients with a new onset of at least one of the following: dysuria, frequency or urgency of urination, hematuria, tenderness of costo-vertebral angle (CVA); or pain in the perineum, flank or suprapubic. Participants received usual clinical care, with treating clinicians obtaining pre-treatment urinalysis for 93% (253 of 272 participants) and pre-treatment urine culture for 87.9% (239).

Attending clinicians prescribed ciprofloxacin for 57% of participants (156) and trimethoprim / sufamethoxazole for 43% (116). Non-inferiority was established if less than 10% of those receiving 7 days of antibiotics versus 14 days remained symptomatic at 14 and 28 days. .

Drekonja and colleagues reported resolution of symptoms in 91.9% of the 7-day randomized treatment group, encountering non-inferiority compared to 90.4% with resolution of symptoms among randomized participants receiving treatment regimens of 14 days. There was also a statistically similar proportion of participants randomized to the two groups reported symptom recurrence at 28-day follow-up, although numerically higher with 14 days of treatment (10.3% of the 7-day group versus 16 , 9% in the 14-day group). Non-inferiority remained in post-hoc analysis regardless of the antibiotic, the level of bacteriuria before treatment, or whether bacteriuria was confirmed or not tested.

Drekonja and colleagues conclude that 7 days of antibiotic treatment was no less than 14 days for resolution of UTI symptoms, and suggest that their results should be applicable in practice.

“This trial was conducted as a pragmatic treatment duration trial in male veterans who had been diagnosed and being treated for UTI by clinical staff,” the investigators noted. As such, the trial was designed to reflect routine clinical practice, in which clinicians do not routinely order a urine culture when managing a case of suspected urinary tract infection.

Morgan and Coffey describe this study as “the most rigorous to date in evaluating the duration of antibiotic therapy in male urinary tract infections”. They agree with the findings that 7 days of antibiotic treatment was not less than 14 days; and that the results should be applied in practice.

“Shorter courses of antibiotic treatment are inherently easier for patients and are preferred when clinical results are not inferior to those of a longer course of treatment,” said Morgan and Coffey.

“This study should inform guidelines and give clinicians the confidence to treat thoughtfully for the shortest effective treatment duration,” they noted.

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