Ibuprofen instead of antibiotics for UTI?

Do all women with uncomplicated UTI’s require antibiotics?

Apparently not.

Of course one would expect some UTI’s to resolve spontaneously. Otherwise the human species would have died out thousands of years ago! But in the era of antibiotics, should we adopt a watchful waiting approach?

This double-blind RCT recruited 494 women from one of 42 GP practices in Germany. They were randomized to either ibuprofen or a single dose of fosfomycin.

The primary endpoints were the number of courses of antibiotics and the total burden of symptoms on days 0 to 7.

Results? Two thirds of the ibuprofen group recovered with no antibiotics. Holy smokes!

But unfortunately, they did have higher burden of symptoms as reported on a non-intuitive scale. (To me, they looked pretty similar.) In addition, there were 5 cases of pyelonephritis in the ibuprofen group as compared to 1 in the fosfomycin group.

Urine cultures were positive in about 75% with a pretty low bar of >10² cfu/ml. So who knows if some women never had UTI’s in the first place. Placebo works pretty well for non-bacterial illness. (We know this from treatment of “otitis media” and the Pollyanna phenomenon.) However, I think it is reasonable to assume that many really did have bacterial cystitis.

Another concern is external validity. It is possible that the patients who present to a GP practice are less sick then those who come to the ED. Insert cynical comment here...

So what to do with this information?

There are probably some women with simple UTI symptoms that do not need antibiotics. They will recover just fine with symptomatic therapy. When and in whom to do this is the big question.

The authors suggest a shared decision making strategy with a possible prescription for delayed antibiotics if no improvement. I think this sounds reasonable with some caution.

I also find many doctors make a soft-call diagnosis of UTI and reach for the prescription pad. Perhaps we could wait and see before resorting to antibiotics.

Two thirds better with nothing… pretty impressive.

Covering:

Gagyor I, Bleidorn J, Kochen MK, et al. Ibuprofen versusfosfomycin for uncomplicated urinary tract infection in women: randomisedcontrolled trial. BMJ 2015;351:h6544