Symptomatic treatment inferior to antibiotics in women with UTIs

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Certain NSAIDs may prevent antibiotic overuse in some UTI cases.
Certain NSAIDs may prevent antibiotic overuse in some UTI cases.

Symptomatically treating uncomplicated lower urinary tract infections (UTIs) with non-steroidal anti-inflammatory drugs (NSAIDs) decreases antibiotic usage but not symptom relief time, according to a study in the BMJ.

In a randomized, double-blind study ranging from February 2012 to December 2014, Andreas Kronenberg, MD, of the Institute for Infectious Diseases at the University of Bern in Bern, Switzerland, and associates tested 253 women diagnosed with uncomplicated lower UTIs to determine if the use of NSAIDs would reduce the need for antibiotics in symptomatic treatment of UTIs.

 

Computer-generated randomization was used to distribute either diclofenac (133 women) or an antibiotic treatment containing norfloxacin (120 women). Women were monitored for symptom relief at day 3 (primary outcome) and day 30 with the use of any antibiotic (secondary outcome).

In the primary outcome, 72 women on diclofenac (54%) reported that their symptoms were resolved on day 3, and 96 women on norfloxacin (80%) had symptom resolution in the same time (risk difference, 27%). The median symptom resolution time for patients taking diclofenac vs norfloxacin was 4 days and 2 days, respectively (hazard ratio, 1.64).

To prevent pyelonephritis, the researchers monitored the patients for unplanned doctor visits, loin pain, and fever. None of the patients taking norfloxacin, but 5% of the patients taking diclofenac, were clinically diagnosed with pyelonephritis.

At day 30, 82 women (62%) in the diclofenac group and 118 (98%) in the norfloxacin group had taken an antibiotic for their UTI. Of the 82 women taking diclofenac, 71% took an antibiotic during the first 3 days. Fosfomycin was optionally administered as a rescue antibiotic, taken by 95% of the women who took an antibiotic from the diclofenac group.

Women who took an NSAID were 27% less likely to have symptom relief by day 3 and 12% less likely after day 7 compared with the women taking the antibiotic treatment. The placebo, therefore, increased the occurrence of patients developing pyelonephritis and lowered overall patient satisfaction with the treatment.

Though the diclofenac treatment did not alleviate patient UTI symptoms as quickly as the norfloxacin treatment, women taking the NSAID were 37% less likely to receive antibiotics until day 30. The study authors hope that this decrease will help limit the use of antibiotics and decrease resistance in an ambulatory setting.

“Reduction in antibiotic use, which would likely contribute directly to decreasing resistance rates in affected population, suggests that alternative approaches of combining symptomatic treatment with deferred, selective antibiotic use should be developed and tested in future trials,” Dr Kronenberg's group stated. 

In an accompanying editorial, Paul Little, MBBS, BA, MD, DLSHTM, MRCP, FRECGP, FMedSci, Professor of Primary Care Research at the University of Southampton, Southampton, United Kingdom, wrote, “when advocating an NSAID clinicians could consider advising women to take ibuprofen rather than diclofenac because in the previous larger study, which used ibuprofen, pyelonephritis occurred less often.” 

Reference

  1. Kronenberg A, Bütikofer L, Odutago A, Mühlemann K, da Costa BR, Battaglia M, et al. Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomized, double blind trial. BMJ. 2017 Nov 7. doi: 10.1136/bmj.j4787
  2. Little P. Antibiotics or NSAIDs for uncomplicated urinary tract infection? BMJ. 2017 Nov 8. BMJ 2017;359:j5037
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