Duration of treatment with third- and fourth-generation quinolones and pivmecillinam could be shorter than the currently recommended regimens and still serve to effectively manage acute uncomplicated cystitis, according to a review recently published in the Lancet Infectious Diseases.
Uncomplicated urinary tract infection (UTI), an infection in healthy people without anatomical or functional urinary tract abnormalities, occurs more frequently in women than men, with 40% to 50% of women experiencing at least 1 infection in their lifetime. Most uncomplicated UTI infections in women are associated with symptoms of frequency, urgency, and dysuria. In real-world practice, urine culture is not mandatory and diagnosis involves history, physical examination, and urinalysis, and clinical guidelines recommend empirical antibiotic treatment. The International Clinical Practice Guidelines for Treatment of Acute Uncomplicated Cystitis in women were updated in 2010 and recommend a single dose of fosfomycin trometamol, a 3-day regimen of trimethoprim and sulfamethoxazole (co-trimoxazole), a 5-day regimen of nitrofurantoin, and 3-day and 7-day regimens of pivmecillinam. Studies have suggested that shorter-term antimicrobial therapy may be just as effective or even advantageous over longer-term regimens for acute uncomplicated cystitis; however, shorter regimens are not always adopted in clinical guidelines. Therefore, a team of investigators conducted a systemic review and network meta-analysis to investigate the effectiveness of reduced duration of guideline-approved antibiotic regimens for acute uncomplicated cystitis.
In total, 61 randomized trials that included 20,780 patients were identified through a search of PubMed, Embase, and the Cochrane Library. All included clinical trials assessed antibiotic therapy in women with acute uncomplicated cystitis and reported clinical or microbial response outcomes.
Results suggest that shorter-term antimicrobial therapy is just as effective as longer-term therapy for acute uncomplicated cystitis. Although a treatment duration of 3 to 7 days is recommended for pivmecillinam, clinical responses in patients receiving 5-day and 7-day regimens were similar to those receiving a 3-day regimen, with evidence of moderate quality (risk ratio [RR] 1.041 for 5 days; 1.095 for 7 days). A similar clinical response was seen between a 3-day regimen and single dose of third-generation and fourth-generation fluoroquinolones, with evidence of moderate quality (RR 0.994 vs 1.024). Conversely, 3-day regimens of second-generation quinolones and co-trimoxazole were associated with greater clinical response than single-dose regimens, also with evidence of moderate quality. No difference was observed in clinical response between single-dose and 3-day regimens for third-generation cephalosporins, amoxicillin, and clavulanate, but evidence quality was low or very low.
Overall, the review authors conclude, “Because antibiotic resistance has been increasing substantially worldwide, a shorter treatment duration can be beneficial in minimizing antibiotic resistance and collateral damage and reducing antibiotic-related costs and adverse effects. From this point of view, our findings are thought to be valuable.”
Kim DK, Kim JH, Lee JY, et al. Reappraisal of the treatment duration of antibiotic regimens for acute uncomplicated cystitis in adult women: a systemic review and network meta-analysis of 61 randomised clinical trials. Lancet Infect Dis. doi:10.1016/S1473-3099(20)30121-3