Ibuprofen vs fosfomycin for uncomplicated UTI in women
The Article: Gágyor, I, et al. “Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial.” BMJ 2015;351:h6544
The Idea: In general practice, uncomplicated UTIs account for 25% of Abx prescriptions. Prescription of Abx contributes to rates of resistance, and uncomplicated UTIs are often self limited. In this study, general practitioners in Germany compared symptom burden in women with uncomplicated UTIs treated symptomatically with ibuprofen vs fosfomycin to determine if the number of prescriptions for uncomplicated UTIs can be reduced.
The Study: This study was a double blind randomized multicenter comparative effectiveness trial from February 2012- February 2014.
Included women aged 18-65 years old presenting to 42 primary care practices in northern Germany with typical UTI symptoms (which were dysuria and/or urinary frequency/urgency, +/- lower abdominal pain). Excluded patients with symptoms of pyelonephritis, pregnancy, renal disease, UTI within the past 2 weeks, urinary catheterization, current NSAID use, current antibiotic use, history of GI ulcers, severe acute or exacerbated chronic conditions. Qualifying patients were randomized to one of the treatment arms. Patients were advised to consult their PCP if symptoms persisted or worsened, at which time they would be started on antibiotics based on urine culture from initial visit, regardless of treatment arm.
The co-primary endpoints were:
1) total number of courses of antibiotics on days 0-28
2) burden of symptoms on days 0-7
Results: The total number of antibiotic courses was reduced in the ibuprofen group (reduction rate 66.5%). A total of 283 courses were prescribed in the fosfomycin group (243 for the study, 34 additional for UTI, 6 additional for other reasons), and a total of 94 were prescribed in the ibuprofen group (81 additional for UTI, 18 additional for other reasons).
The symptom burden in both groups decreased from day 0 to day 7, but the symptom burden in the ibuprofen group was larger, as evidenced by an area under the curve ratio of 140% (exceeding non-inferiority margin of 125%). There were 5 cases of pyelonephritis in the ibuprofen group vs 1 in the fosfomycin group.
The Takeaway: This paper demonstrates that symptomatic treatment of uncomplicated UTIs does decreased prescription of antibiotics, but at the cost of increased symptom burden and incidence and pyelonephritis compared to those given antibiotics. Interestingly, two-thirds of patients in the ibuprofen treatment arm recovered without need for antibiotics, so further research may be able to identify patients in whom symptomatic treatment alone is sufficient.