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Evidence summaries

Oral Treatment for Symptomatic Severe Urinary Tract Infections in Non-Elderly

Oral antibiotic therapy appears to be as effective as parenteral or initial parenteral therapy for severe urinary tract infection. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 15 studies with a total of 1743 subjects. Initial intravenous or intramuscular therapy followed by oral therapy was defined as switch treatment. Studies compared oral vs switch treatment (5 studies n=1040), switch vs parenteral treatment (6 trials, n=373), and single dose parenteral followed by oral therapy vs oral or switch therapy. There were a variety of short-term and long-term outcomes, but no pooled outcomes showed significant differences. Only one small trial studied oral vs parenteral treatment, parenteral therapy had better bacterial cure than oral norfloxacin. The only assessed long-term outcome was kidney scarring, and scarring does not seem to differ.

Comment: The quality of evidence is downgraded by study quality.

A systematic review 2 compared the effectiveness of short and long courses of oral antibiotics for infections treated in outpatient settings. There was no difference in the clinical cure for adults treated with short or long course antibiotics for uncomplicated cystitis (3 vs 5 days or longer) in non-pregnant women (RR 1.10, 95% CI 0.96 to 1.25; 32 studies, n=9605), or elderly women (RR: 0.98, 95% CI:0.62, 1.54; 6 studies, n=431); acute pyelonephritis (7-14 vs 14-42 days) (RR: 1.03, 95% CI 0.80 to 1.32; 2 trials, n=185); acute bacterial sinusitis; or community acquired pneumonia. No adequate evidence about the effect on antibiotic resistance was found.

Another systematic review 3 included 5 RCTs involving a total of 1003 subjects. Success of oral treatment of the outpatient pyelonephritis by cefaclor, ciprofloxacin and norfloxacin at 4 to 6 weeks was comparable at between 83 to 95%. Relatively high rates of adverse events were noted in a trial of ciprofloxacin (24%) and trimethoprim-sulfamethoxazole (33%).

    References

    • Pohl A. Modes of administration of antibiotics for symptomatic severe urinary tract infections. Cochrane Database Syst Rev 2007 Oct 17;(4):CD003237. [PubMed]
    • Dawson-Hahn EE, Mickan S, Onakpoya I et al. Short-course versus long-course oral antibiotic treatment for infections treated in outpatient settings: a review of systematic reviews. Fam Pract 2017;34(5):511-519. [PubMed]
    • Cattrall JWS, Robinson AV, Kirby A. A systematic review of randomised clinical trials for oral antibiotic treatment of acute pyelonephritis. Eur J Clin Microbiol Infect Dis 2018;37(12):2285-2291.[PubMed]

Primary/Secondary Keywords