Shorter Course of Antibiotics Effective for UTI in Men

Seven days of antibiotics were found as effective as 14 days in treating urinary tract infections (UTI) in afebrile men, in a randomized controlled trial assessing symptom resolution and following for recurrence among patients of 2 Veterans Affairs (VA) medical centers.

Dimitri Drekonja, MD, MS, Minneapolis VA Health Care System, Minnesota, and colleagues noted that UTI is among the most common indications for antibiotics, and reasoned that a study providing definitive evidence of the noninferiority of shorter treatments "has the potential to substantially decrease antimicrobial use, particularly for agents active against gram-negative bacteria, in which emerging resistance is of great concern."

In an accompanying editorial, Daniel Morgan, MD, MS and Karen Coffey, MD, MPH, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, point out that UTI in men has traditionally been treated for longer periods than in women, often assuming it is required for an infection that develops despite the relative anatomical barrier of the longer male urethra.

Morgan and Coffey also note that while the Infectious Disease Society of America (IDSA) has guidance for the treatment of uncomplicated UTI in women, there is no corresponding guideline for men, "due, in part, to limited data".

To contribute to these data, Drekonja and colleagues at the 2 VA sites randomized 272 participants diagnosed with UTI and treated with 7 days of either ciprofloxacin or trimethoprim/sulfamethoxaxole to either an additional 7 days of the antibiotic or placebo.The investigators noted that agents such as amoxicillin-clavulanate are increasingly used in lieu of ciprofloxacin, but that patients received the antibiotics commonly used in the VA at the time of the study (April 2014 through December 2019 in Minneapolis, and January 2018 through December 2019 in Houston).

All participants were outpatients presenting with new onset of at least 1 of the following: dysuria, frequency or urgency of urination, hematuria, costovertebral angle (CVA) tenderness; or perineal, flank, or suprapubic pain.The participants received usual clinic care, with treating clinicians obtaining pretreatment urinalysis for 93% (253 of 272 participants) and pretreatment urine culture for 87.9% (239).

The treating clinicians prescribed ciprofloxacin for 57% of participants (156) and trimethoprim/sufamethoxazole for 43% (116).Noninferiority was established if fewer than 10% of those receiving 7 days of antibiotics compared to 14 days remained symptomatic at 14 and 28 days.

Drekonja and colleagues reported symptom resolution in 91.9% of the as-randomized 7-day treatment group, meeting non-inferiority to the 90.4% with symptom resolution among the as-randomized participants receiving 14 day regimens.There was also a statistically similar proportion of as-randomized participants in both groups reporting recurrence of symptoms at the 28 day follow-up, albeit numerically higher with 14 days of treatment (10.3% of the 7-day group vs 16.9% in the 14-day group).Noninferiority remained in post-hoc analysis regardless of the antibiotic, the level of pretreatment bacteriuria, or whether bacteriuria was confirmed or untested.

Drekonja and colleagues conclude that 7 days of antibiotic treatment was noninferior to 14 days for resolution of UTI symptoms, and suggest that their findings should be applicable to practice.

"This trial was conducted as a pragmatic trial of treatment duration among male veterans who had been diagnosed with and were being treated for UTI by clinical staff," the investigators noted. "As such, the trial was designed to reflect routine clinical practice, in which clinicians do not consistently order a urine culture when managing a case of suspected UTI."

Morgan and Coffey describe this study as “the most rigorous to date in evaluating antibiotic duration in male UTI”.They concur with the conclusions that 7 days of antibiotic treatment was noninferior to 14 days; and that the findings should be applied to practice.

“Shorter courses of antibiotic treatment are inherently easier for patients and are preferred when clinical outcomes are noninferior compared with longer duration of treatment,” Morgan and Coffey indicated.

“This study should inform guidelines and should give clinicians confidence to treat thoughtfully for the shortest effective treatment duration,” they remarked.