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Evidence summaries

Antimicrobial Agents for Treating Uncomplicated Urinary Tract Infection in Women

Trimethoprim-sulfamethoxazole (TMP-SMX), beta-lactam drugs and nitrofurantoin are equally effective for uncomplicated urinary tract infection in women. Single-dose fosfomycin may be effective. Level of evidence: "A"

A multinational, open-label, analyst-blinded, clinical trial 2 included 513 nonpregnant women aged 18 years and older with symptoms of lower UTI, a positive urine dipstick result, and no known colonization or previous infection with resistant uropathogens. Women were randomized in a 1:1 ratio to oral nitrofurantoin, 100 mg 3 times a day for 5 days, or a single 3-g dose of oral fosfomycin. Clinical resolution through day 28 was achieved in 171 of 244 patients (70%) receiving nitrofurantoin vs 139 of 241 patients (58%) receiving fosfomycin (difference 12%, 95% CI 4% to 21%). Microbiologic resolution occurred in 129 of 175 (74%) vs 103 of 163 (63%), respectively (difference 11%, 95% CI 1% to 20%). Adverse events were few and primarily gastrointestinal; the most common were nausea and diarrhea (7/248 and 3/248 in the nitrofurantoin group vs 5/247 and 5/247 in the fosfomycin group, respectively).

A Cochrane review [Abstract] 1 included 21 studies with a total of 6016 subjects. Different antimicrobial treatments (7 days) for acute uncomplicated lower UTI were compared. Short-term cure was defined as absence of urinary symptoms up to 2 weeks after start of treatment or negative urine culture within 2 weeks, and long-term follow-up was up to 8 weeks. For symptomatic cure, no difference was found between different antimicrobial treatments (trimethoprim-sulfamethoxazole (TMP-SMX), fluoroquinolones, beta-lactam drugs, and nitrofurantoin), see table T1. For bacteriological cure, fluoroquinolones were more effective than beta-lactams in short-term, but not more effective than TMP-SMX. Rashes were more frequent with TMP-SMX than with nitrofurantoin or fluoroquinolones and with beta-lactam drugs compared to fluoroquinolones. Minimal data were available on resistant strains during or after antimicrobial treatment.

Clinical comment: Consider the drug resistance when choosing the treatment. Fluoroquinolones are not recommended for lower UTI.

Different antibiotics for uncomplicated urinary tract infection in women

StudiesPatientsInterventionControlOutcomeRisk ratio and 95% ClOutcome in words
Symptomatic cure
5 RCTs927fluoroquinoloneTMP-SMXShort-termRR 1.00 (0.97 to 1.03)No difference
1 RCT614fluoroquinoloneTMP-SMXLong-termRR 0.99 (0.94 to 1.05)No difference
2 RCTs176beta-lactamsTMP-SMXShort-termRR 0.95 (0.81 to 1.12)No difference
2 RCTs138beta-lactamsTMP-SMXLong-termRR 1.06 (0.93 to 1.21)No difference
3 RCTs733nitrofurantoinTMP-SMXShort-termRR 0.99 (0.95 to 1.04)No difference
2 RCTs338nitrofurantoinTMP-SMXLong-termRR 1.01 (0.94 to 1.09)No difference
1 RCT51nitrofurantoinbeta-lactamsShort-termRR 1.19 (0.93 to 1.51)No difference
2 RCTs1192fluoroquinolonebeta-lactamsShort-termRR 1.15 (0.99 to 1.32)No difference
Bacteriological cure
5 RCTs1289fluoroquinolonebeta-lactamsShort-termRR 1.22 (1.13 to 1.31)Fluoroquinolones slightly more effective than beta-lactams
7 RCTs1253fluoroquinoloneTMP-SMXShort-termRR 1.03 (1.00 to 1.07)No difference
6 RCTs884fluoroquinoloneTMP-SMXLong-termRR 1.06 (1.00 to 1.12)No difference
5 RCTs389beta-lactamsTMP-SMXShort-termRR 0.95 (0.88 to 1.04)No difference
5 RCTs311beta-lactamsTMP-SMXLong-termRR 0.97 (0.87 to 1.08)No difference
2 RCTs170nitrofurantoinbeta-lactamsShort-termRR 1.09 (0.75 to 1.58)No difference
2 RCTs143nitrofurantoinbeta-lactamsLong-termRR 0.97 (0.86 to 1.09)No difference
4 RCTs668nitrofurantoinTMP-SMXShort-termRR 0.97 (0.87 to 1.08)No difference
3 RCTs395nitrofurantoinTMP-SMXLong-termRR 1.01 (0.90 to 1.13)No difference

References

  • Zalmanovici Trestioreanu A, Green H, Paul M et al. Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database Syst Rev 2010;10:CD007182 [PubMed]
  • Huttner A, Kowalczyk A, Turjeman A et al. Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women: A Randomized Clinical Trial. JAMA 2018;319(17):1781-1789.[PubMed]

Primary/Secondary Keywords