Antimicrobial agents for treating acute uncomplicated urinary tract infection in women

Acute uncomplicated lower urinary tract infection (UTI), also know as cystitis, is characterised by burning on urination and frequent urination without fever or flank pain. It is a common event in otherwise healthy, non-pregnant adult women. A large range of antimicrobials are used in the treatment of cystitis. Twenty one good quality studies, enrolling 6016 participants, which used different classes of antimicrobials for treating acute cystitis in women for 3 up to 10 days, were included in this review. The classes of antimicrobials included in the review proved equally effective for the symptomatic cure. Fluoroquinolones proved more effective than beta-lactams for the short-term bacteriological cure, but the significance of this finding is doubtful. Fewer rashes developed in patients treated with fluoroquinolones. Nitrofurantoin caused fewer rashes than TMP-SMX while having similar rates of any adverse events. Given the small number of studies included in each comparison and for each outcome it is recommended that further randomised controlled trials be conducted.

Authors' conclusions: 

No differences were observed between the classes of antimicrobials included in this review for the symptomatic cure of acute uncomplicated UTI. Fluoroquinolones proved more effective than beta-lactams for the short-term bacteriological outcome, probably with little clinical significance. Individualised treatment should take into consideration the predictable susceptibility of urinary pathogens in local areas, possible adverse events and resistance development, and patient preference.

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Background: 

Acute uncomplicated lower urinary tract infection (UTI) is one of the most common problems for which young women seek medical attention.

Objectives: 

To compare the efficacy, resistance development and safety of different antimicrobial treatments for acute uncomplicated lower UTI.

Search strategy: 

In February 2010 we searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Renal Group's Specialised Register, MEDLINE, EMBASE and bibliographies of included studies.

Selection criteria: 

Randomised controlled trials (RCTs) comparing different classes of antimicrobials for acute uncomplicated UTI in women were included. The outcomes of interest were symptomatic and bacteriological cure at short and long-term follow-up, resistance development, number of days to symptom resolution, days of work loss, adverse events and complications.

Data collection and analysis: 

Two authors independently extracted the data and assessed study quality. Statistical analyses were performed using the random effects model and the results expressed as risk ratios (RR) with 95% confidence intervals (CI).

Main results: 

We included 21 studies (6016 participants) in this review. Trimethoprim-sulfamethoxazole (TMP-SMX) was as effective as fluoroquinolones in achieving short-term (RR 1.00, 95% CI 0.97 to 1.03) and long-term (RR 0.99, 95% CI 0.94 to 1.05) symptomatic cure. Beta-lactam drugs were as effective as TMP-SMX for short-term (RR 0.95, 95% CI 0.81 to 1.12) and long-term (RR 1.06, 95% CI 0.93 to 1.21) symptomatic cure. Short-term cure for nitrofurantoin was similar to that of TMP-SMX (RR 0.99, 95% CI 0.95 to 1.04) as was long-term symptomatic cure (RR 1.01, 95% CI 0.94 to 1.09).

Fluoroquinolones were more effective than beta-lactams (RR 1.22, 95% CI 1.13 to 1.31) for short-term bacteriological cure. Rashes were more frequent in patients treated with TMP-SMX than with nitrofurantoin or fluoroquinolones and in patients treated with beta-lactam drugs compared to fluoroquinolones. Minimal data were available on the emergence of resistant strains during or after antimicrobial treatment.

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