Three-day treatment of acute lower urinary tract infections in women. A double-blind study with amoxycillin and co-trimazine

Unitary Tract Infection Treatment: When to Use What Agents including Beta-lactam Combination Agents

In this study, the authors review antibiotic treatment options for both acute uncomplicated and complicated urinary tract infection (UTI). In addition, they also review regimens used in the setting of drug-resistant pathogens including vancomycin resistant Enterococcus, extended spectrum beta-lactamase (ESBL) producing Enterobacterals, carbapenem-resistant Enterobacterals and carbapenem-resistant Pseudomonas, which are encountered with increasing frequency.

Revisiting β-Lactams for Treatment of Urinary Tract Infections: Assessing Clinical Outcomes of Twice-Daily Cephalexin for Empiric Treatment of Uncomplicated Urinary Tract Infections

The 2011 Infectious Diseases Society of America guidelines for treatment of uncomplicated urinary tract infections (UTIs) recommend non-β-lactam antibiotics for empiric therapy. However, increasing Escherichia coli and Klebsiella spp. resistance to first-line antibiotic therapies has necessitated the need for alternative agents. Based on local antibiogram data, cephalexin has become the preferred oral antibiotic for empiric treatment of UTIs at our institution. The purpose of this single-center retrospective review was to assess clinical outcomes of patients discharged from the emergency department (ED) who received cephalexin for the treatment of uncomplicated UTIs. The primary outcome of this study was to assess the proportion of patients with clinical success 30 days after discharge from the ED. Patients were excluded if they were <18 years of age, received ≥10 days of cephalexin, received antibiotics for any indication other than uncomplicated UTI, received antibiotics within 60 days of their ED visit, or had structural abnormalities. A total of 264 patients were included for evaluation, and 214 patients (81.1%) met the criteria for clinical success. Overall, 28 (10.6%) patients required a change in antibiotics based on cultures and sensitivities, 18 (6.8%) patients returned for nonresolving or worsening symptoms, and 4 (1.5%) patients required both a change in antibiotics and returned for nonresolving or worsening symptoms. Short courses of twice-daily cephalexin appear to be a safe and effective option for the empiric treatment of uncomplicated UTIs.

Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women

BACKGROUND

Urinary tract infections (UTI) are common in elderly patients. Authors of non systematic literature reviews often recommend longer treatment durations (7 to 14 days) for older women, but the evidence for such recommendations is unclear.

OBJECTIVES

To determine the optimal duration of antibiotic treatment for uncomplicated symptomatic lower UTI in elderly women.

SEARCH STRATEGY

We contacted known investigators and pharmaceutical companies, screened reference lists of identified articles, reviews and books, and searched MEDLINE, EMBASE, CINAHL, Healthstar, Popline, Gerolit, Bioethics Line, The Cochrane Library, Dissertation Abstracts International and Index to Scientific & Technical Proceedings without language restriction. Date of most recent search: 7 May 2008.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing different treatment durations of oral antibiotics for uncomplicated symptomatic lower UTIs in elderly women were included. Whenever possible we obtained outcome data for older women included in studies with a broader age range. We excluded patients with fever, flank pain or complicating factors; studies with treatment durations longer than 14 days and prevention studies.

DATA COLLECTION AND ANALYSIS

The two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random effects model and results expressed as risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

Fifteen studies (1644 elderly women) were included. Three studies compared single dose with short-course treatment (3 to 6 days), six compared single dose with long-course treatment (7 to 14 days) and six compared short- with long-course treatment. Methodological quality of all studies was low except for a more recent geriatric study. There was a significant difference for persistent UTI between single dose and short-course treatment (RR 2.01, 95% CI 1.05 to 3.84) and single versus long-course treatment (RR 1.93, 1.01 to 3.70 95% CI), in the short-term (< 2 weeks post-treatment) but not at long-term follow-up or on clinical outcomes. Patients preferred single dose treatment (RR 0.73, 95% CI 0.60 to 0.88) to long-course treatments, but this was based on one study comparing different antibiotics. Short versus longer treatments showed no significant difference in efficacy. Rate of adverse drug reactions increased significantly with longer treatment durations in only one study.

AUTHORS' CONCLUSIONS

Short-course treatment (3 to 6 days) could be sufficient for treating uncomplicated UTIs in elderly women, although more studies on specific commonly prescribed antibiotics are needed.

Tratamiento de las infecciones no complicadas del tracto urinario inferior

Empirical antibiotic treatment of lower urinary tract infections should be based on the patient's clinical data and on local sensitivity data. Because of the increase in resistance among uropathogens, recommendations on the empirical treatment of urinary tract infections have been modified. Currently, the empirical use of co-trimoxazole, ampicillin, and first-generation cephalosporins and quinolones is not recommended. Fluoroquinolones have been demonstrated to be highly effective in comparative studies but, because of the increase in resistance, the type of patient who can benefit from these antimicrobial agents must be selected. Second- and third-generation cephalosporins still have high sensitivity rates, although the higher recurrence rates associated with their use and the emergence of extended-spectrum beta-lactamase-producing enterobacterial in the community should be taken into account. Amoxicillin-clavulanate is less effective in eradicating infections than quinolones. Fosfomycin-trometamol has resistance rates of below 2% and single-dose therapy has been demonstrated to be safe and effective. Nitrofurantoin is also currently active, although it must be administered for 7 days and can produce toxicity. Both agents are currently recommended as alternative therapeutic options to fluoroquinolones in uncomplicated infections of the lower urinary tract.

All dysuria is local. A cost-effectiveness model for designing site-specific management algorithms

OBJECTIVE

To determine the cost-effectiveness of management strategies for dysuria in different office settings.

DESIGN

Decision and cost-effectiveness analyses, assuming the payer's perspective. Data on disease prevalence, test characteristics, treatment efficacy, and adverse effects were drawn from the English language literature using medline searches and bibliographies.

SETTING

Hypothetical primary care practice.

PATIENTS

Otherwise healthy, nonpregnant women with symptoms of dysuria, urgency, and frequency.

INTERVENTIONS

All reasonable combinations of urinalysis, urine culture, pelvic examination, chlamydia and gonorrhea cultures, and empiric treatment with trimethoprim-sulfamethoxazole.

RESULTS

The cost-effectiveness of strategies varied substantially among different patient settings. In all settings, empiric trimethoprim-sulfamethoxazole for all patients was least expensive and least effective. Most testing increased both cost and effectiveness. Compared to empiric antibiotics, performing pelvic examination and urine culture for women with normal urinalyses had a marginal cost-effectiveness ratio of $4 to $32 per symptom-day avoided (SDA). Adding urine culture for patients with pyuria had a marginal cost of $34 to $107 per SDA, which fell to $40/SDA when the prevalence of resistance to trimethoprim-sulfamethoxazole exceeded 40%. Pelvic examination and urine culture for all patients regardless of urinalysis results achieved the greatest benefit but at the highest cost (>$300 per SDA).

CONCLUSIONS

In otherwise healthy women with symptoms of dysuria and no vaginal complaints, performing pelvic exam and urine culture based on urinalysis offers a reasonable alternative to empiric therapy. Other testing may be warranted, depending on antibiotic resistance and the value of avoiding a day of dysuria.

The current management strategies for community-acquired urinary tract infection

Acute uncomplicated UTI is one of the most common problems for which young women seek medical attention and accounts for considerable morbidity and health care costs. Acute cystitis or pyelonephritis in the adult patient should be considered uncomplicated if the patient is not pregnant or elderly, if there has been no recent instrumentation or antimicrobial treatment, and if there are no known functional or anatomic abnormalities of the genitourinary tract. Most of these infections are caused by E. coli, which are susceptible to many oral antimicrobials, although resistance is increasing to some of the commonly used agents, especially TMP-SMX. In women with risk factors for infection with resistant bacteria, or in the setting of a high prevalence of TMP-SMX-resistant uropathogens, a case can be made for using a fluoroquinolone or nitrofurantoin. Use of nitrofurantoin for the empiric treatment of mild cystitis is supportable from a public health perspective in an attempt to decrease uropathogen resistance because it does not share cross-resistance with more commonly prescribed antimicrobials. Beta-lactams and fosfomycin should be considered second-line agents for empiric treatment of cystitis. Acute pyelonephritis in an otherwise healthy woman may be considered an uncomplicated infection. Fluoroquinolone regimens are superior to TMP-SMX for empiric therapy because of the relatively high prevalence of TMP-SMX resistance among uropathogens causing pyelonephritis. TMP-SMX, effective for patients with mild to moderate disease, is an appropriate drug if the uropathogen is known to be susceptible. It is reasonable to use a 7- to 10-day oral fluoroquinolone regimen for outpatient management of mild to moderate pyelonephritis in the setting of a susceptible causative pathogen and rapid clinical response to therapy. Most women with acute uncomplicated pyelonephritis are now managed safely and effectively as outpatients. Acute uncomplicated cystitis or pyelonephritis in healthy adult men is very uncommon but is generally caused by the same spectrum of uropathogens with the same antimicrobial susceptibility profile as that seen in women. The choice of antimicrobials is similar to that recommended for cystitis in women except that nitrofurantoin is not considered a good choice. Treatment duration should generally be longer than that recommended for women.

Correlation between pharmacokinetic/pharmacodynamic parameters and efficacy for antibiotics in the treatment of urinary tract infection

Antibiotic treatment of urinary tract infection (UTI) depends on the antibiotic being able to inhibit the growth or to kill the bacteria present in the urinary tract. The pharmacokinetics of antibiotics in the urinary tract including the kidneys, the bladder and the prostate are briefly reviewed. The conclusion is that high urinary antibiotic concentrations can eradicate bacteria in the urine, but in the kidney tissue levels must surpass the MIC of the infecting pathogen to achieve effect. Pharmacodynamic studies in UTI are relatively scarce, but recent studies have shown, that as for other types of infections, beta-lactam antibiotic treatment of UTI depends on the T(>MIC), i.e. the time the antibiotic concentration remains above the MIC. This counts for activity against bacteria in the kidneys as well as in the urine. Bacterial counts in the bladder are curiously resistant to the activity of most antibiotics. For drugs with concentration dependent time-kill activity such as the fluoroquinolones and the aminoglycosides, the effect in UTIs is dependent on the peak/MIC ratio or AUC/MIC ratio. The aminoglycosides are difficult to evaluate in this context, since they are bound in high concentrations to the renal cortex. For clinical studies the author reviews the literature for aminopenicillins (ampicillin and amoxycillin) as representatives of beta-lactam antibiotics. Data from 16 studies of uncomplicated UTI encompassing 20 treatment groups showed a significant correlation between the cumulative T(>MIC) and bacteriological cure, such that a cumulative T(>MIC) of 30 h was necessary for a maximal cure rate of 80-90%. Incorporating these data including the T(>MIC) for the aminopenicillins, the optimal dose with minimal consumption of drug can be calculated, i.e. for amoxycillin 500 mg TID for 4 days. Further research is needed to calculate optimal dosages for other types of antibiotics, especially in order to prevent development of resistance.

Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women

BACKGROUND

Urinary tract infections are common in elderly patients. Authors of non systematic literature reviews often recommend longer treatment durations (7-14 days) for older patients than for younger women, but the scientific evidence for such recommendations is not clear.

OBJECTIVES

To determine the optimal duration of antibiotic treatment for uncomplicated symptomatic lower urinary tract infections in elderly women.

SEARCH STRATEGY

We contacted known investigators and pharmaceutical companies marketing antibiotics used to treat urinary tract infections, screened the reference list of identified articles, reviews and books, and searched the following data bases: MEDLINE, EMBASE, CINAHL, Healthstar, Popline, Gerolit, Bioethics Line, The Cochrane Library, Dissertation Abstracts International, Index to Scientific & Technical Proceedings.

SELECTION CRITERIA

All randomized controlled trials in which different treatment durations of oral antibiotics for uncomplicated symptomatic lower urinary tract infections in elderly women were compared. We excluded patients with fever or flank pain and those with complicating factors. Trials with treatment durations longer than 14 days or designed for prevention of urinary tract infection were also excluded. No language restriction was applied.

DATA COLLECTION AND ANALYSIS

The quality of all selected trials was assessed and data extracted by the reviewers. Main outcome measures were persistence of urinary symptoms (short-term and long-term efficacy), effect on mental and functional status and adverse drug reactions. To compare the different treatment durations, we defined the following categories of duration: single dose, short course (3-6 days) and long course (7-14 days). Relative risk (RR) and 95% confidence intervals (CI) were calculated for each trial and outcome and were then combined using a random effects model.

MAIN RESULTS

Thirteen trials were included in this review. Six trials compared single dose with short-term treatment (3-6 days), three studies single dose with long-term treatment (7-14 days) and four trials short-term with long term treatment. Eight trials also included younger patients, but provided a subgroup analysis for elderly women. The methodological quality of all trials was low. All trials reported results of bacteriological cure rate; less often clinical outcomes (e.g. improvement or cure of symptoms) were analyzed. Only five trials compared the same antibiotic given for a different length of time. We performed a separate analysis for these trials. The rate of persistent bacteriuria rate at short-term (two weeks post-treatment) was better in the longer treatment group (3-14 days) than in the single dose group (RR 1.84, 95% CI 1.18 to 2.86). However, the rate of persistent bacteria at long term and the clinical cure rate showed no statistically significant difference between the two groups. Patients showed a preference for single dose treatment (RR 0.73, 95% CI 0.66 to 0.88), however this was based on only one trial comparing the same antibiotic. The comparison of short (3-6 days) and longer treatments (7-14 days) did not show any significant difference, but the number of included studies and sample size were low.

REVIEWER'S CONCLUSIONS

This review suggests that single dose antibiotic treatment is less effective but may be better accepted by the patients than longer treatment durations (3-14 days). In addition there was no significant difference between short course (3-6 days) versus longer course (7-14 days) antibiotics. The methodological quality of the identified trials was poor and the optimal treatment duration could not be determined. We therefore need more appropriately designed randomized controlled trials testing the effect, - on clinical relevant outcomes -, of different treatment durations of a given antibiotic in a strictly defined population of elderly women.

Urinary tract infections, antibiotic resistance and sales of antimicrobial drugs--an observational study of uncomplicated urinary tract infections in Icelandic women

OBJECTIVES

To analyse the antimicrobial susceptibility pattern of bacteria causing symptomatic but otherwise uncomplicated lower urinary tract infections (UTI) in primary health care and the sales of antimicrobial drugs.

SETTING

Primary health care in Akureyri District, Northern Iceland, with about 17400 inhabitants.

PATIENTS

A total of 516 episodes of symptomatic but otherwise uncomplicated lower UTI in women 10 to 69 years of age.

MAIN OUTCOME MEASURES

Number of verified UTI, bacterial species, antimicrobial susceptibility pattern, and total sales of antimicrobial drugs.

RESULTS

Escherichia coli was by far the most common cause of UTI (83%), followed by Staphylococcus saprophyticus (7%). Infections caused by E. coli resistant to ampicillin accounted for 36% of cases, with the corresponding figures for sulfafurazol being 37%, cephalothin 45%, trimethoprim 13% and mecillinam 14%. Only 1% of the strains were resistant to nitrofurantoin. The total use of antimicrobial drugs was 17.4 DDD/1000 inhabitants/day.

CONCLUSIONS

The resistance of bacteria causing uncomplicated UTI to common antimicrobials is high and must be taken into account when selecting treatment strategies. High consumption of antibiotics in the community indicates possible association.

Acute urinary tract infection in women. What kind of antibiotic therapy is optimal?

Urinary tract infections continue to be a major health problem for women. Understanding of the pathogenesis of urinary tract infections has improved; Staphylococcus saprophyticus has been recognized as a common causative agent, and low-colony-count infections are misdiagnosed less often. Traditional therapy with 10 days of amoxicillin (Amoxil, Wymox) or ampicillin (Omnipen, Totacillin) is no longer considered optimal. For women who fulfill certain clinical criteria, short-course therapy is recommended--preferably 3 days of trimethoprim-sulfamethoxazole, or trimethoprim alone (Proloprim, Trimpex) if the woman is allergic to sulfonamides. Longer therapy is indicated for women with complicated, prolonged, or recurrent infections. To appropriately treat patients and avoid overtreatment that would increase both costs and the incidence of side effects, physicians need to stay abreast of information about pathogens, mechanisms of disease, new drugs, and common resistance patterns.

Urinary tract infection in primary health care in northern Sweden. III. Bacteriology in relation to clinical and epidemiological factors

The spectrum of bacteria causing urinary tract infection (UTI) and their patterns of drug resistance were found to be more associated with the process of selecting the patients and their sex and age than with the symptoms of the patient (lower, upper or asymptomatic UTI). UTI caused by Staphylococcus saprophyticus was seen mainly in female patients in primary health care (PHC), showed a peak in August and was rarely complicated by therapeutic failures or recurrences. The average risk of resistance of the infecting strain to the seven drugs tested increased from eight per cent for the uncomplicated and 17% for the average PHC patient to 36% among PHC patients with indwelling catheter or urinary incontinence, whereas recurrences of UTI were associated with a surprisingly small increase of drug resistance. In all UTI patient groups studied, the lowest incidences of bacterial resistance were recorded for trimethoprim and co-trimoxazole (0-17%). Thus, rational selection of UTI therapy in PHC requires knowledge of the influence of clinical factors on the expected bacteriology including the local pattern of drug resistance.

Comparison of three- and ten-day regimens with a sulfadiazine-trimethoprim combination and pivmecillinam in acute lower urinary tract infections

132 female hospital employees (mean age 32 years) with uncomplicated, bacteriologically verified acute lower urinary tract infection were included in a randomized study. The patients were treated for 3 or 10 days with a sulfadiazine-trimethoprim combination (500 mg + 150 mg) b.i.d. or for 3 or 10 days with pivmecillinam (500 mg) t.i.d. The first follow-up evaluation was performed 3-5 days after the treatment. In both sulfadiazine-trimethoprim groups the cure rate was 97% and in both pivmecillinam groups 80%. This difference was mainly due to the occurrence of pivmecillinam-resistant Staphylococcus saprophyticus strains. 109 patients attended the second follow-up visit about 4 weeks after treatment. The prevalences of reinfections and relapses were 18% in both 3-day regimens and 4-7% in both 10-day regimens. No side-effects were reported in the 3-day sulfadiazine-trimethoprim group, while about 20% in the corresponding 10-day group had side-effects. Side-effects were not common in patients treated with pivmecillinam.

Cefadroxil once daily for three or seven days versus amoxycillin for seven days in uncomplicated urinary tract infections in women

The cure rate of acute uncomplicated urinary tract infection in general practice using 3 different treatment regimens, was studied in a randomized, multicenter trial. Patients were assigned to receive either cefadroxil 1 g once daily for 3 or 7 days or amoxycillin 375 mg t.i.d. for 7 days. 310 patients entered the study, of whom 230 could be evaluated according to the protocol. Two thirds of the cases were due to infections with Escherichia coli and about one fourth to Staphylococcus saprophyticus. No statistically significant differences in cure rates between the 3 regimens could be demonstrated neither at 1 week nor at 5 weeks of follow-up. The frequency of adverse reactions was low and similar in each treatment group.