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Evidence summaries

Treatment Duration of Febrile Urinary Tract Infection

5-7 days of fluoroquinolone is effective for pyelonephritis in women compared with longer (10-14 days) treatment. Level of evidence: "A"

Summary

A randomized placebo-controlled, double-blind, non-inferiority trial among 35 primary care centers and 7 emergency departments of regional hospitals in the Netherlands 1 included a total of 200 adults. Patients received antibiotic treatment for 7 or 14 days (first week ciprofloxacin, the second week ciprofloxacin 500 mg or placebo orally twice daily. Short-term clinical cure occurred in 85 (90%) patients treated for 7 days and in 94 (95%) of those treated for 14 days (difference -4.5%; 90% CI -10.7 to 1.7; P non-inferiority = 0.072, non-inferiority not confirmed). In women, clinical cure was 94% and 93% in those treated for 7 and 14 days, respectively (difference 0.9; 90% CI, -6.9 to 8.7, P non-inferiority = 0.011, non-inferiority confirmed) and, in men, this was 86% versus 98% (difference -11.2; 90% CI -20.6 to -1.8, P superiority = 0.025, inferiority confirmed). The bacteriologic cure rate was 93% versus 97% (difference -4.3%; 90% CI, -9.7 to 1.2, P non-inferiority = 0.041) and the long-term clinical cure rate was 92% versus 91% (difference 1.6%; 90% CI, -5.3 to 8.4; P non-inferiority = 0.005) for 7 days versus 14 days of treatment, respectively.

An open-label prospective randomized trial 2 compared 5 days to 10 days of fluoroquinolone treatment for acute pyelonephritis in100 women. In the post-hoc analysis, clinical cure 10 days after the end of the treatment was 28/30 (93.3%) in the 5-day arm and 36/38 (94.7%) in the 10-day arm (p = 1.00). At day 30, the clinical cure rate was 100% in the 5-day arm and 100% in the 10-day arm (p = 1.00). The microbiological cure rate was 87.0% in the 5-day arm and 80.0% in the 10-day arm (p = 1.00).

Another prospective, open-label, randomized, controlled, multicenter, non-inferiority clinical trial 4 compared intravenous levofloxacin 750 mg/day for 5 days or a conventional therapy group with intravenous/oral levofloxacin at 500 mg/day for 7-14 days. Clinical effectiveness in the short-course therapy group (89.87%, 142/158) was non-inferior to that in the conventional therapy group (89.31%, 142/159). The microbiological effectiveness rates were also similar (short-course therapy: 89.55%, 60/67; conventional therapy: 86.30%, 63/73; p > 0.05).

Another prospective, non-inferiority multicentre trial 5 compared the efficacy of ciprofloxacin for 7 days (73 women) and 14 days (83 women). Short-term clinical cure occurred in 71 (97%) in 7-day group and 80 (96%)in 14-day group (difference -0·9%; 90% CI -6·5 to 4·8; p=0·004; non-inferiority test).Cumulative efficacy at long-term follow-up was 93% in each group (68 of 73 vs 78 of 84; -0·3%; -7·4 to 7·2; p=0·015).

A multicenter, retrospective study 3 compared 14 days of trimethoprim-sulfamethoxazole (TMP-SMX) to 7 days of ciprofloxacin for the treatment of pyelonephritis. In an adjusted model, the likelihood of a recurrent UTI within 30 days for the TMP-SMX and ciprofloxacin groups was similar (aOR: 2.30, 95% CI 0.72-7.42; n=272 women).

A randomized trial 6 randomized women to oral ciprofloxacin, 500 mg twice per day for 7 days followed by placebo for 7 days (n = 128 included in analysis) vs trimethoprim-sulfamethoxazole, 160/800 mg twice per day for 14 days (n = 127 included in the analysis). At 4 to 11 days posttherapy, bacteriologic cure rates were 99% (112 of 113) for the ciprofloxacin regimen and 89% (90 of 101) for the trimethoprim-sulfamethoxazole regimen (95% CI 0.04 to 0.16; P = .004). Clinical cure rates were 96% for ciprofloxacin and 83% for trimethoprim-sulfamethoxazole (95% CI, 0.06 to 0.22; P = .002). Escherichia coli, which caused more than 90% of infections, was more frequently resistant to trimethoprim-sulfamethoxazole (18%) than to ciprofloxacin (0%; P<.001).

Clinical comments

Note

Date of latest search: 2019-03-26

    References

    • van Nieuwkoop C, van der Starre WE, Stalenhoef JE et al. Treatment duration of febrile urinary tract infection: a pragmatic randomized, double-blind, placebo-controlled non-inferiority trial in men and women. BMC Med 2017;15(1):70. [PubMed]
    • Dinh A, Davido B, Etienne M et al. Is 5 days of oral fluoroquinolone enough for acute uncomplicated pyelonephritis? The DTP randomized trial. Eur J Clin Microbiol Infect Dis 2017;36(8):1443-1448. [PubMed]
    • Fox MT, Melia MT, Same RG et al. A Seven-Day Course of TMP-SMX May Be as Effective as a Seven-Day Course of Ciprofloxacin for the Treatment of Pyelonephritis. Am J Med 2017;130(7):842-845. [PubMed]
    • Ren H, Li X, Ni ZH et al. Treatment of complicated urinary tract infection and acute pyelonephritis by short-course intravenous levofloxacin (750 mg/day) or conventional intravenous/oral levofloxacin (500 mg/day): prospective, open-label, randomized, controlled, multicenter, non-inferiority clinical trial. Int Urol Nephrol 2017;49(3):499-507. [PubMed]
    • Sandberg T, Skoog G, Hermansson AB et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet 2012;380(9840):484-90. [PubMed]
    • Talan DA, Stamm WE, Hooton TM et al. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis pyelonephritis in women: a randomized trial. JAMA 2000;283(12):1583-90. [PubMed]

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