Clinical question: Are 14 days of antibiotic treatment better than 7 days in afebrile men with urinary tract infection (UTI)?
Background: In the era of antibiotic stewardship, a large body of evidence has led to treating various infections (e.g., pneumonia, UTI in women, cellulitis, etc.) with shorter durations of antibiotics. Shorter treatment durations increase compliance, reduce cost as well as adverse effects, and help control the emergence of antibiotic resistance.
Study design: Randomized, double-blind, placebo-controlled, noninferiority trial
Setting: Two U.S. Veterans Affairs medical centers in Minneapolis and Houston
Synopsis: Out of 1,058 eligible men, 272 were randomized. Afebrile men with presumed UTI were treated with 7 days of either ciprofloxacin or sulfamethoxazole-trimethoprim and then randomized to receive either continued antibiotic therapy (n=136) or placebo (n=136) for days 8 to 14 of treatment. The primary outcome was the resolution of UTI symptoms by 14 days of completion of active antibiotic treatment. Secondary outcomes were the recurrence of symptoms and adverse effects of treatment. Symptom resolution occurred in 93.1% in the 7-day group versus 90.42% in the 14-day group (difference, 2.9% which met the noninferiority cut-off). Recurrence of symptoms occurred in 9.9 % in the 7-day group and 12.9% in the 14-day group (p=0.70). Adverse effects occurred in 20.6% of the 7-day group and 23.4% in the 14-day group. Limitations included empiric treatment of UTI in a subset of patients, with pre-treatment urinalysis obtained in 93% of participants and pre-treatment urine culture in 12.1% of participants. Enrollment did not reach the planned 290 participants, thus possibly decreasing study power to identify statistical significance.
Bottom line: In afebrile men with suspected UTI, treatment with ciprofloxacin or sulfamethoxazole-trimethoprim for 7 days is non-inferior to 14 days with respect to the resolution of UTI symptoms.
Citation: Drekonja DM, et al. Effect of 7 vs 14 days of antibiotic therapy on resolution of symptoms among afebrile men with urinary tract infection: A randomized clinical trial. JAMA. 2021;326(4):324-31.
Dr. Modha is a staff physician in the department of hospital medicine at the Cleveland Clinic, Cleveland, and an assistant professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University of Medicine.