Motivation: In my first week of internship, I have seen more urinary tract infections than just about anything else. The first treatment response for uncomplicated UTI is a three day course of Bactrim, but what happens when the patient either is allergic to Bactrim or has resistant bacteria? The second choice has been ciprofloxacin. But, flipping open UpToDate the other day, I read to my surprise that nitrofurantoin is the recommended first line agent after Bactrim. The issue got even more complicated when the venerable Goodman & Gilman's claimed that nitrofurantoin should be a second line agent. So, what are the data and recommendations?
Paper: Trestioreanu, Z. et. al. Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database Syst. Rev. (2010) 10:CD007182. http://www.ncbi.nlm.nih.gov/pubmed/20927755
Methods: A meta-analysis of randomized trials with the objective of comparing the efficacy and safety of different empiric antibacterial treatments for acute, uncomplicated UTI in healthy women aged 16-65 years. The primary outcomes were short (2 weeks) and long term (8 weeks) symptomatic cures.
Results:
Fluoroquinolone vs Bactrim: Both fluoroquinolones and Bactrim are equally effective as empiric therapy for UTI in the short (CI: 0.97-1.03) and long term (CI: 0.94-1.05) . Overall, there is no difference in adverse effects among the two agents, but patients treated with fluoroquinolones are less likely to develop rash (CI: 0.01-0.43).
Nitrofurantoin vs Bactrim: Both nitrofurantoin and Bactrim are equally effective for UTI treatment in the short (CI: 0.95-1.05) and long term (CI: 0.94-1.09). Overall, no difference in adverse effects for the two agents, but patients treated with nitrofurantoin were less likely to develop rash (0.04-0.76).
The meta-analysis did not find sufficient studies to compare nitrofurantoin to fluroquinolone head-to-head. The analysis went on to further describe efficacies of beta-lactams (which are not summarized here).
Discussion: The surprising fact of the matter is that there are generally no differences in efficacy when treating UTI empirically with fluoroquinolone, Bactrim, or nitrofurantoin. The decision to promote Bactrim stems more from a public health perspective since resistance to fluoroquinolones is increasing. Decreased prescription of fluoroquinolones would presumably decrease generation of resistant bacteria. In empiric treatment of uncomplicated UTI, nitrofurantoin is an excellent alternative to Bactrim and less likely to generate the adverse effect of rashes. Overall, both Bactrim and nitrofurantoin have equivalent severity of side-effects and equivalent efficacy. Of note, however, this meta-analysis examined uncomplicated UTI in unhospitalized patients, and the data might be different in hospitalized patients with Foley catheters in place!
Paper: Trestioreanu, Z. et. al. Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database Syst. Rev. (2010) 10:CD007182. http://www.ncbi.nlm.nih.gov/pubmed/20927755
Methods: A meta-analysis of randomized trials with the objective of comparing the efficacy and safety of different empiric antibacterial treatments for acute, uncomplicated UTI in healthy women aged 16-65 years. The primary outcomes were short (2 weeks) and long term (8 weeks) symptomatic cures.
Results:
Fluoroquinolone vs Bactrim: Both fluoroquinolones and Bactrim are equally effective as empiric therapy for UTI in the short (CI: 0.97-1.03) and long term (CI: 0.94-1.05) . Overall, there is no difference in adverse effects among the two agents, but patients treated with fluoroquinolones are less likely to develop rash (CI: 0.01-0.43).
Nitrofurantoin vs Bactrim: Both nitrofurantoin and Bactrim are equally effective for UTI treatment in the short (CI: 0.95-1.05) and long term (CI: 0.94-1.09). Overall, no difference in adverse effects for the two agents, but patients treated with nitrofurantoin were less likely to develop rash (0.04-0.76).
The meta-analysis did not find sufficient studies to compare nitrofurantoin to fluroquinolone head-to-head. The analysis went on to further describe efficacies of beta-lactams (which are not summarized here).
Discussion: The surprising fact of the matter is that there are generally no differences in efficacy when treating UTI empirically with fluoroquinolone, Bactrim, or nitrofurantoin. The decision to promote Bactrim stems more from a public health perspective since resistance to fluoroquinolones is increasing. Decreased prescription of fluoroquinolones would presumably decrease generation of resistant bacteria. In empiric treatment of uncomplicated UTI, nitrofurantoin is an excellent alternative to Bactrim and less likely to generate the adverse effect of rashes. Overall, both Bactrim and nitrofurantoin have equivalent severity of side-effects and equivalent efficacy. Of note, however, this meta-analysis examined uncomplicated UTI in unhospitalized patients, and the data might be different in hospitalized patients with Foley catheters in place!
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