Ibuprofen versus phosphomycin for women with uncomplicated urinary tract infections

The guideline on ‘Urinary Tract Infections’ published by the Dutch College of General Practitioners (NHG) recommends that the treatment of first choice for healthy non-pregnant women (aged over 12 years) should be a five-day course of nitrofurantoin if antibiotics are required.3 It is well-known that Escherichia coli is the main pathogen causing urinary tract infections (Gebu 2012; 46: 73-79). The drug of first choice in Germany is phosphomycin, as the level of resistance to nitrofurantoin is higher there. The resistance level of E. coli to phosphomycin is still very low in both Germany and the Netherlands,4 5 so failure of phosphomycin treatment due to resistance is unlikely. The gold standard for diagnosing urinary tract infection in the Netherlands is urine culture.
According to the above guideline, GPs can offer a ‘delayed antibiotics prescription’ to healthy non-pregnant women with a suspected or diagnosed urinary tract infection (see also the article on pp. 59–60 in this issue of GEBU). This implies that the patient waits for 48 hours before starting the antibiotic treatment and in the meantime drinks sufficient fluids and uses an analgesic if necessary.3 A previous randomised study among 79 patients, comparable to the study discussed here, compared the efficacy of ibuprofen with that of ciprofloxacin, and found that 58% of the ibuprofen group were free of complaints after four days, compared to 52% of the group of patients using ciprofloxacin.6 However, that study had insufficient statistical power to allow clear conclusions to be drawn. The study discussed here, using the AUC0-7 as a measure of the severity and duration of symptoms, this outcome measure proved significantly higher in the ibuprofen group than in the phosphomycin group. Another similar study randomised 309 women (aged 18–70 yrs.) with symptoms of uncomplicated urinary tract infection to five treatment strategies, including immediate antibiotics therapy and delayed prescription. The study found that the symptoms lasted longer among the women who delayed their antibiotics therapy for 48 hours or more.7 A 2009 meta-analysis of five randomised placebo-controlled studies, involving over 1000 patients, to evaluate the efficacy of antibiotics for the treatment of acute uncomplicated urinary tract infections among non-pregnant adult women, concluded that antibiotics were significantly more effective than placebo in reducing symptoms, but also that they caused significantly more side-effects.8
The studies discussed above show that the burden of symptoms in treatment involving delayed prescription is slightly less favourable than the present NHG guideline suggests. On the other hand, a wait-and-see policy involving delayed antibiotics prescription with analgesics if needed could reduce the use of antibiotics. Women with mild to moderate symptoms should be carefully informed of the greater burden of symptoms and the fact that this policy carries few risks: no studies have so far produced evidence that the incidence of pyelonephritis as a complication is significantly higher if uncomplicated urinary tract infections are not (or not immediately) treated with antibiotics.2 8

References*

  1. Ga voorzichtig om met antibiotica. Ministerie van Volksgezondheid, Welzijn en Sport. [document op internet]. Via: www.daarwordtiedereenbetervan.nl.
  2. Gágyor I, et al. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial. BMJ 2015; 351: h6544.
  3. Pinxteren B van, et al. NHG-Standaard ’Urineweginfecties’ (derde herziening). Huisarts Wet 2013; 56: 270-280.
  4. Schito GC, et al. The ARESC study: an international survey on the antimicrobial resistance of pathogens involved in uncomplicated urinary tract infections. Int J Antimicrob Agents 2009; 34: 407-413.
  5. NethMap 2015. Consumption of antimicrobial agents and antimicrobial resistance among medically important bacteria in the Netherlands in 2014. [document op het internet]. Stichting Werkgroep Antibiotica Beleid (SWAB). Via: http://www.swab.nl/swab/cms3.nsf/uploads/4F5A0D8E6F0DD139C1257E6E0051833A/$FILE/NethmapMaran2015%20_webversie.pdf.
  6. Bleidorn J, et al. Symptomatic treatment (ibuprofen) or antibiotics (ciprofloxacin) for uncomplicated urinary tract infection?–results of a randomized controlled pilot trial. BMC Med 2010; doi: 10.1186/1741-7015-8-30.
  7. Little P, et al. Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. BMJ 2010; 340: c199.
  8. Falagas ME, et al. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta-analysis of randomized controlled trials. J Infect 2009; 58: 91-102.

*The literature refers to the Dutch text

Authors

  • mw L. Boogaard