November 22, 2017
Although the NSAID diclofenac decreased antibiotic use among women with uncomplicated lower UTI, it increased the median duration of symptoms and may elevate the risk for pyelonephritis, compared with the antibiotic norfloxacin, according to findings published in the BMJ.
“UTI is one of the most common bacterial infections in adults, affecting considerably more women than men... Antibiotic prescriptions for UTI account for 10% to 20% of all antibiotic prescriptions in ambulatory care and are second only to antibiotic prescriptions for respiratory tract infections,” Andreas Kronenberg, MD, from the Institute for Infectious Diseases, University of Bern, Switzerland, and colleagues wrote. “Reducing antibiotic prescriptions for UTI could potentially decrease the risk of antibiotic resistance.”
Kronenberg and colleagues conducted a randomized, double-blind trial to determine if NSAIDs are noninferior to antibiotics for resolution of symptoms in cases of uncomplicated lower UTI in women. The researchers enrolled 253 women uncomplicated lower UTI from 17 general practices in Switzerland and randomly assigned them to receive treatment for symptoms of UTI with either the NSAID diclofenac (n = 133) or the antibiotic norfloxacin (n = 120).
Symptom resolution at day 3, 72 hours after randomization and 12 hours after receiving the last study drug, was experienced by more women in the norfloxacin group than the diclofenac group (80% vs. 54%; risk difference = 27%; 95% CI, 15-38; P < .001 for superiority). Women receiving diclofenac had a median time until symptom resolution of 4 days, while those receiving norfloxacin had a median time of 2 days.
Use of antibiotics up to day 30 was observed in 62% of women in the diclofenac group and 98% of those in the norfloxacin group (risk difference = 37%; 95% CI, 28-46). Five percent of women receiving diclofenac and no women receiving norfloxacin were diagnosed with pyelonephritis.
“The observed clinically relevant reduction in antibiotic use, which would likely contribute directly to decreasing resistance rates in the affected population, suggests that alternative approaches of combining symptomatic treatment with deferred, selective antibiotic use should be developed and tested in future trials,” Kronenberg and colleagues concluded. – by Alaina Tedesco
Disclosure: Kronenberg reports receiving travel grant and meeting expenses from Gilead, Viofor and the WHO. He also reports that he is an advisor of the Swiss Federal Office of Public Health. Please see study for all other authors’ relevant financial disclosures.
James E. Bryant
Concern for increasing antimicrobial resistance has led to efforts to decrease antibiotic usage.
There are confounding aspects to the trial by Kronenberg and colleagues. Twenty-five percent of each group actually had negative cultures. Of the women in the NSAID arm who decided to take antibiotics, 71% took them in the first 3 days. On subanalysis, resolution and complete absence of symptoms at day 3 were more common in women who never received antibiotics. Finally, 34 women with positive cultures were not treated with antibiotics and 16 of these converted to negative at day 10.
These results highlight the challenge in diagnosis and treatment of UTIs. Some women do quite well treated only symptomatically, but it is difficult to define those women with this study because of crossover. Symptomatic treatment could be offered while awaiting the results of the culture. Point of care culture technology allows results in 24 hours. Initiation of antibiotic therapy could then be determined by urine culture and also response to symptomatic treatment alone. The challenge is the diverse presentation and treatment response of patient with this diagnosis.
- James E. Bryant, MD
- Assistant Professor
VP of Clinical Affairs
Department of Urology, University of Alabama at Birmingham
Disclosures: Bryant reports no relevant financial disclosures.