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NSAIDs inferior to antibiotics in treating UTIs

Non-steroidal anti-inflammatory drugs (NSAIDs) were found to be inferior to antibiotics for symptom relief of uncomplicated urinary tract infection (UTI), according to findings from a Swiss study.

In this study, the researchers led by Andreas Kronenberg, at the Institute for Infectious Diseases, University of Bern and Medix General Practice Network, Bern, Switzerland, sought to investigate whether NSAIDs could provide symptomatic treatment for uncomplicated UTI in women, potentially reducing the need for antibiotic use in ambulatory care. They conducted a double-blind, randomised trial in 17 general practices in Switzerland; a total of 253 women with an uncomplicated lower UTI were enrolled.

One-hundred-and-thirty-three were randomly assigned to treatment with the NSAID diclofenac while 120 were assigned to the antibiotic norfloxacin.

The primary endpoint of symptom resolution at day 3 was met by 54% (72/133) in the diclofenac group vs 80% (96/120) in the norfloxacin group (risk difference 27%, 95% CI 15% to 38%, P =.98 for non-inferiority, P <.001 for superiority). The diclofenac group had a median symptom resolution time of 4 days, while symptoms in the norfloxacin group resolved on average at 2 days.

Additionally, 6 individuals (5%) in the diclofenac treatment group progressed to a pyelonephritis diagnosis (P =.03) compared to none in the norfloxacin group.

The authors conclude that "symptomatic treatment is inferior to antibiotic treatment for women with uncomplicated lower UTI in an ambulatory setting, as it increases median symptom duration by 2 days and is likely to be associated with an increased risk of clinically diagnosed pyelonephritis."

Objective: To investigate whether symptomatic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) is non-inferior to antibiotics in the treatment of uncomplicated lower urinary tract infection (UTI) in women, thus offering an opportunity to reduce antibiotic use in ambulatory care.
Design: Randomised, double blind, non-inferiority trial.
Setting: 17 general practices in Switzerland.
Participants: 253 women with uncomplicated lower UTI were randomly assigned 1:1 to symptomatic treatment with the NSAID diclofenac (n=133) or antibiotic treatment with norfloxacin (n=120). The randomisation sequence was computer generated, stratified by practice, blocked, and concealed using sealed, sequentially numbered drug containers.
Main outcome measures: The primary outcome was resolution of symptoms at day 3 (72 hours after randomisation and 12 hours after intake of the last study drug). The prespecified principal secondary outcome was the use of any antibiotic (including norfloxacin and fosfomycin as trial drugs) up to day 30. Analysis was by intention to treat.
Results: 72/133 (54%) women assigned to diclofenac and 96/120 (80%) assigned to norfloxacin experienced symptom resolution at day 3 (risk difference 27%, 95% confidence interval 15% to 38%, P=0.98 for non-inferiority, P<0.001 for superiority). The median time until resolution of symptoms was four days in the diclofenac group and two days in the norfloxacin group. A total of 82 (62%) women in the diclofenac group and 118 (98%) in the norfloxacin group used antibiotics up to day 30 (risk difference 37%, 28% to 46%, P<0.001 for superiority). Six women in the diclofenac group (5%) but none in the norfloxacin group received a clinical diagnosis of pyelonephritis (P=0.03).
Conclusion: Diclofenac is inferior to norfloxacin for symptom relief of UTI and is likely to be associated with an increased risk of pyelonephritis, even though it reduces antibiotic use in women with uncomplicated lower UTI.

Andreas Kronenberg, Lukas Bütikofer, Ayodele Odutayo, Kathrin Mühlemann, Bruno R da Costa, Markus Battaglia, Damian N Meli, Peter Frey, Andreas Limacher, Stephan Reichenbach, Peter Jüni

[link url=""]Infectious Disease Advisor material[/link]
[link url=""]BMJ abstract[/link]

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