Frequent readers of this blog may have noticed a bit of an anti-antibiotic tendency. Diverticulitis! Strep throat! All manner of upper respiratory symptoms!
How about urinary tract infections?
This German study randomized ambulatory women with urinary tract infection symptoms and positive findings on urine dipstick to either fosfomycin plus placebo tablets for three days, or simply ibuprofen for three days. Patients were then reassessed after three days, and those with treatment failure were provided an additional course of antibiotics. “Co-primary” endpoints were antibiotics utilization and the AUC of sums of daily symptom scores.
The results are, like last week’s URI trial, a little mixed. The authors included 484 patients in their intention-to-treat analysis, and 77% of them ultimately had culture-positive UTIs. A lot – 69% – of patients randomized to ibuprofen had spontaneous resolution of their symptoms and avoided antibiotic use for their UTI. However, obviously, those who did not improve spontaneously, and ultimately were given antibiotics, did worse than their fosfomycin counterparts – and the symptom scores clearly favored the antibiotic cohort. Furthermore, 5 of 241 of patients randomized to ibuprofen advanced to pyelonephritis, and one more patient suffered ulcer-related bleeding due to ibuprofen.
I’m not sure how many women would opt for the trial of ibuprofen as part of a shared decision-making conversation, were practice to be based on this specific trial. That said, it does raise a bit of an interesting question regarding potential strategies to reduce antibiotic use. Would a 24- or 48-hour “waiting period” help? If routine urine cultures weren’t already grossly low-value care, could waiting for those results help triage appropriate use of antibiotics? Could a different symptom adjunct, such as pyridium, help reduce the difference in symptom scores while awaiting spontaneous resolution?
Regardless, it is is yet again an insight into the general effectiveness of the human body’s natural antibacterial defense mechanisms. How much of modern medicine is critically important – and how much is simply are mildly harmful minor ameliorations of mostly self-limited disease processes?
“Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial”
http://www.bmj.com/content/351/bmj.h6544