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

Estimating daily antibiotic harms: an umbrella review with individual study meta-analysis

BACKGROUND

There is growing evidence supporting the efficacy of shorter courses of antibiotic therapy for common infections. However, the risks of prolonged antibiotic duration are underappreciated.

OBJECTIVES

To estimate the incremental daily risk of antibiotic-associated harms.

METHODS

We searched three major databases to retrieve systematic reviews from 2000 to 30 July 2020 in any language.

ELIGIBILITY

Systematic reviews were required to evaluate shorter versus longer antibiotic therapy with fixed durations between 3 and 14 days. Randomized controlled trials included for meta-analysis were identified from the systematic reviews.

PARTICIPANTS

Adult and paediatric patients from any setting.

INTERVENTIONS

Primary outcomes were the proportion of patients experiencing adverse drug events, superinfections and antimicrobial resistance.

RISK OF BIAS ASSESSMENT

Each randomized controlled trial was evaluated for quality by extracting the assessment reported by each systematic review.

DATA SYNTHESIS

The daily odds ratio (OR) of antibiotic harm was estimated and pooled using random effects meta-analysis.

RESULTS

Thirty-five systematic reviews encompassing 71 eligible randomized controlled trials were included. Studies most commonly evaluated duration of therapy for respiratory tract (n = 36, 51%) and urinary tract (n = 29, 41%) infections. Overall, 23 174 patients were evaluated for antibiotic-associated harms. Adverse events (n = 20 345), superinfections (n = 5776) and antimicrobial resistance (n = 2330) were identified in 19.9% (n = 4039), 4.8% (n = 280) and 10.6% (n = 246) of patients, respectively. Each day of antibiotic therapy was associated with 4% increased odds of experiencing an adverse event (OR 1.04, 95% CI 1.02-1.07). Daily odds of severe adverse effects also increased (OR 1.09, 95% CI 1.00-1.19). The daily incremental odds of superinfection and antimicrobial resistance were OR 0.98 (0.92-1.06) and OR 1.03 (0.98-1.07), respectively.

CONCLUSION

Each additional day of antibiotic therapy is associated with measurable antibiotic harm, particularly adverse events. These data may provide additional context for clinicians when weighing benefits versus risks of prolonged antibiotic therapy.

Oral cephalosporin and β-lactamase inhibitor combinations for ESBL-producing Enterobacteriaceae urinary tract infections

ESBL-producing Enterobacteriaceae as uropathogens have given rise to a sizeable amount of global morbidity. Community and hospital surveillance studies continue to report increasing proportions of these organisms as causes of urinary tract infection (UTI). Due to limited treatment options and the presence of cross-resistance amongst oral antibiotics of different classes, patients often require IV therapy, thereby increasing healthcare costs and reducing the effectiveness of delivering healthcare. Oral cephalosporin antibiotics are well known for their ability to achieve high urinary concentrations, in addition to achieving clinical success for treatment of uncomplicated UTI with a drug-susceptible pathogen. Novel cephalosporin/β-lactamase inhibitor combinations have been developed and demonstrate good in vitro activity against ESBL-producing isolates. A pooled analysis of in vitro activity of existing oral cephalosporin/clavulanate combinations in ESBL-producing Enterobacteriaceae has shown MIC50s of 0.5-1, 0.125-1 and 0.25 mg/L for cefpodoxime, ceftibuten and cefixime, respectively. A novel cyclic boronic acid β-lactamase inhibitor, QPX7728, was able to produce MIC50 values of 0.5 and ≤0.06 mg/L when paired with cefpodoxime and ceftibuten, respectively. Other novel combinations, cefpodoxime/ETX0282 and ceftibuten/VNRX7145, have also demonstrated excellent activity against ESBL producers. Clinical trials are now awaited.

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.

Three-day vs longer duration of antibiotic treatment for cystitis in women: systematic review and meta-analysis

PURPOSE

We performed a meta-analysis to ascertain the efficacy and safety of the currently practiced 3-day antibiotic therapy for cystitis versus prolonged therapy (5 days or longer) to relieve symptoms and to achieve bacteriological cure.

METHODS

The Cochrane Library, the Cochrane Renal Group's Register of trials, EMBASE and MEDLINE were searched to identify all randomized controlled trials comparing 3-day oral antibiotic therapy with prolonged therapy (5 days and longer) for uncomplicated cystitis in adult non-pregnant women. Two reviewers independently applied selection criteria, performed quality assessment, and extracted data. Relative risks (RR) with their 95% confidence intervals (CI) were estimated; a fixed effect model was used. An intention-to-treat analysis was performed whenever possible.

RESULTS

Thirty-two trials and 9605 patients met inclusion criteria. For symptomatic failure rates no difference between 3-day and prolonged antibiotic regimens was found at short term (RR 1.16, 95% CI: 0.96-1.41) and long-term follow-up (RR 1.17, 95% CI: 0.99-1.38). Three-day treatment was less effective than prolonged therapy in preventing bacteriological failure, relative risk 1.37 (95% CI: 1.07-1.74) for short-term follow-up, and 1.47 (95% CI: 1.22-1.77) for long-term follow-up. Adverse effects were more common in the prolonged therapy group (RR 0.83, 95% CI: 0.79-0.91). The results were consistent for subgroup and sensitivity analyses.

CONCLUSION

Antibiotic therapy for 3 days is similar to prolonged therapy in achieving symptomatic cure for cystitis, while the prolonged treatment is more effective in obtaining bacteriological cure.

Duration of antibacterial treatment for uncomplicated urinary tract infection in women

BACKGROUND

Uncomplicated urinary tract infection (UTI) is a common disease, occurring frequently in young sexually active women. In the past, seven day antibiotic therapy was recommended while the current practice is to treat uncomplicated UTI for three days.

OBJECTIVES

TO compare the efficacy and safety of three-day antibiotic therapy to multi-day therapy (five days or longer) on relief of symptoms and bacteriuria at short-term and long-term follow-up.

SEARCH STRATEGY

The Cochrane Library (Issue 1, 2004), the Cochrane Renal Group's Register of trials (July 2003), EMBASE (January 1980 to August 2003), and MEDLINE (January 1966 to August 2003) were searched. We scanned references of all included studies and contacted the first or corresponding author of included trials and the pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing three-days oral antibiotic therapy with multi-day therapy (five days and longer) for uncomplicated cystitis in 18 to 65 years old non-pregnant women without signs of upper UTI.

DATA COLLECTION AND ANALYSIS

Data concerning bacteriological and symptomatic failure rates, occurrence of pyelonephritis and adverse effects were extracted independently by two reviewers. Relative risk (RR) and their 95% confidence intervals (CI) were estimated. Outcomes were also extracted by intention-to-treat analysis whenever possible.

MAIN RESULTS

Thirty-two trials (9605 patients) were included. For symptomatic failure rates, no difference between three-day and 5-10 day antibiotic regimen was seen short-term (RR 1.06, 95% CI 0.88 to 1.28) and long-term follow-up (RR 1.09, 95% CI 0.94 to 1.27). Comparison of the bacteriological failure rates showed that three-day therapy was less effective than 5-10 day therapy for the short-term follow-up, however this difference was observed only in the subgroup of trials that used the same antibiotic in the two treatment arms (RR 1.37, 95% CI 1.07 to 1.74, P = 0.01). This difference was more significant at long-term follow-up (RR 1.43, 95% CI 1.19 to 1.73, P = 0.0002). Adverse effects were significantly more common in the 5-10 day treatment group (RR 0.83, 95% CI 0.74 to 0.93, P = 0.0010). Results were consistent for subgroup and sensitivity analyses.

AUTHORS' CONCLUSIONS

Three days of antibiotic therapy is similar to 5-10 days in achieving symptomatic cure during uncomplicated UTI treatment, while the longer treatment is more effective in obtaining bacteriological cure. In spite of the higher rate of adverse effects, treatment for 5-10 days could be considered for treatment of women in whom eradication of bacteriuria is important.

Cefpodoxime-proxetil versus trimethoprim-sulfamethoxazole for short-term therapy of uncomplicated acute cystitis in women

One hundred sixty-three women with uncomplicated acute lower urinary tract infections were included in a multicenter randomized study comparing cefpodoxime-proxetil (one 100-mg tablet twice daily) with trimethoprim-sulfamethoxazole (one double-strength tablet [160/800 mg] twice daily) for 3 days. A total of 30 women in both arms were excluded from the study for various reasons. At 4 to 7 days after the discontinuation of therapy, 62 of 63 (98.4%) cefpodoxime-proxetil recipients and 70 of 70 (100%) trimethoprim-sulfamethoxazole patients were clinically cured and demonstrated bacteriological eradication, respectively. At 28 days after treatment, 48 of 55 (87.3%) and 43 of 50 (86%) cefpodoxime-proxetil recipients as well as 51 of 60 (85%) and 42 of 50 (84%) trimethoprim-sulfamethoxazole recipients were clinically cured and demonstrated bacteriological eradication, respectively. Independently of the prescribed regimen, a significant difference (P < 0.001) in failure rates was observed only for patients with a previous history of three or more episodes of acute cystitis per year. With the exception of one patient in the trimethoprim-sulfamethoxazole arm who discontinued therapy because of gastrointestinal pain, both antimicrobials were well tolerated. In conclusion, cefpodoxime-proxetil treatment for 3 days was as safe and effective as trimethoprim-sulfamethoxazole for 3 days for the treatment of uncomplicated acute cystitis in women.

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.

Double-blind study comparing 3-day regimens of cefixime and ofloxacin in treatment of uncomplicated urinary tract infections in women

This double-blind randomized study compared 3-day regimens of cefixime (400 mg once daily) and ofloxacin (200 mg twice a day) in the treatment of urinary tract infections in women. The respective clinical cure rates for the two groups of women were 89 and 92% after 7 days and 81 and 84% after 4 weeks. The respective microbiological cure rates (free of bacteriuria) for the two groups of women were 83 and 86% after 7 days and 77 and 80% after 28 days. A 3-day cefixime regimen seems to be as efficient as a 3-day ofloxacin regimen in the treatment of uncomplicated cystitis in women.

Optimal characteristics of agents to treat uncomplicated urinary tract infections

The optimal characteristics of agents to treat uncomplicated urinary tract infection must include activity against the major pathogens involved in these infections as well as a low potential for development of bacterial resistance. High urinary levels should be present for an adequate period to eliminate the organisms. Side effects should be minimal with minimal effect on the bacterial flora of the community. Treatment programs of single-dose, three days, or five days can be developed depending upon the agent.

Randomised double-blind study of norfloxacin and cefadroxil in the treatment of acute pyelonephritis

In a coordinated, double-blind multi-centre trial, adults with symptoms of acute pyelonephritis were randomly assigned to receive a two-week course of oral treatment with either 400 mg norfloxacin twice daily or 1 g cefadroxil twice daily. Of 197 patients enrolled in the study, 140 could be evaluated for drug efficacy and 193 for drug safety. Norfloxacin gave a significantly higher bacteriological cure rate than cefadroxil, both at 3 to 10 days (98% versus 65%; p less than 0.0001; 95% confidence interval (CI) for difference in proportions 21-46%) and up to eight weeks (87% versus 48%; p less than 0.0001; 95% CI 25-54%) after cessation of treatment. The differences between the two regimens were most pronounced in men and in patients with complicating factors such as diabetes mellitus and urinary tract abnormalities. The clinical response during treatment did not differ between the two groups, but symptomatic recurrences at follow-up were more common in the cefadroxil group (28% versus 3%; p less than 0.0001; 95% CI 14-36%). Adverse events were more often reported by patients receiving cefadroxil (39% versus 22%; p = 0.011; 95% CI 4-30%) and consisted mainly of gastrointestinal disturbances and vulvo-vaginitis. In terms of bacteriological and clinical efficacy and safety, a two-week course of norfloxacin was superior to a two-week course of cefadroxil for oral treatment of community-acquired acute pyelonephritis.

Double-blind comparison of 3-day versus 7-day treatment with norfloxacin in symptomatic urinary tract infections. The Inter-Nordic Urinary Tract Infection Study Group

The therapeutic efficacy and safety of norfloxacin 400 mg twice daily for 3 or 7 days was compared in a double-blind randomized multiclinic study including 485 female general practice patients with uncomplicated symptomatic lower urinary tract infections. 373 patients were considered valid for efficacy, 193 in the 3-day treatment group and 180 in the 7-day treatment group. The short-term efficacy (elimination of significant bacteriuria 3-13 days post-treatment) was 93.8% and 96.6% in the 3 and 7-day treatment groups, respectively, and the accumulated efficacy (elimination of significant bacteriuria 3 days post-treatment up until 45 days after the first dose) 81.3% and 91.7%, respectively (p less than 0.004). The median time to disappearance of symptoms was 3 days in both groups. Norfloxacin was well tolerated in both treatment groups.

Clinical and bacteriological effects of therapy of urinary tract infection in primary health care: relation to in vitro sensitivity testing

17 primary health care (PHC) centres participated in a 1-month evaluation of a county urinary tract infection (UTI) management program. A total of 302 patients contributing 355 episodes, dominated by female (93%), lower symptomatic (75%) and Escherichia coli (74%) episodes were studied. In therapeutic failure gram-negative bacteria other than E. coli showed an increased prevalence whereas Staphylococcus saprophyticus was not found. The general pattern of drug resistance was little influenced by UTI history and the mean pretherapy prevalence of resistance to the 7 antibacterial agents studied was low (7%). Drug resistance was increased in failure (mean 24%) also for agents not used for therapy (sulphonamides and nitrofurantoin) but not in early or repeated recurrence. UTI symptoms were eradicated in only two-thirds of bacteriologically cured episodes but in one-third of the failures at the posttreatment control. On average, therapy resulted in 8% bacteriological failure and 12% early recurrence. The bacteriological cure rate was the same irrespective of whether the infecting bacteria were classified as sensitive or resistant in vitro to the drug given. Thus, sensitivity testing of isolates is rarely needed in sporadic or recurrent UTI in PHC but may be relevant in failure. In order to be of prognostic value in uncomplicated UTI high-level breakpoints focusing more on peak urinary drug concentrations need to be studied.

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.

Once daily therapy for streptococcal pharyngitis with cefadroxil

To determine if a single daily dose of cefadroxil would be effective in the treatment of group A beta-hemolytic streptococcal (GABHS) pharyngitis, 196 patients with GABHS pharyngitis were randomly assigned to receive either penicillin V 250 mg three times daily or cefadroxil 30 mg/kg once daily, for 10 days. Outcome was measured by the ability to isolate GABHS from the upper respiratory tract 18 to 24 hours after the onset of therapy, the impact on the clinical course, and the bacteriologic treatment failure rate. There was no significant difference in the number of patients in the cefadroxil and penicillin V treatment groups with throat cultures positive for GABHS at the 18 to 24-hour follow-up visit (0% and 2%, respectively), and the clinical responses of the patients in the two treatment groups were similar. Of the 99 patients in the three times daily penicillin V group, six (6%) had strains of GABHS isolated on one of the follow-up cultures that were identical to the strains isolated from their initial throat cultures and were considered to have bacteriologic treatment failures. Of the 96 patients in the once daily cefadroxil group, two (2%) were considered to have bacteriologic treatment failures. A single daily dose of cefadroxil appears to be as effective in the treatment of GABHS pharyngitis in this population as penicillin V given three times daily.