Long Drug Course No Help for UTI in Men (CME/CE)

FG_AUTHORS: MedPage Today

By Charles Bankhead, Staff Writer, MedPage Today
Published: December 04, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

Longer-duration antibiotic therapy for urinary tract infection (UTI) in men had no impact on early or late recurrence, results of a large study showed.

In fact, treatment beyond 7 days increased the likelihood of late recurrence (10.8% versus 8.4%, P<0.001) and slightly, but significantly, increased the frequency of Clostridium difficile infection, reported Dimitri Drekonja, MD, of the Minneapolis VA Health Care System, and colleagues in Archives of Internal Medicine online.

"These findings question the role of longer-duration treatment for male UTI in the outpatient setting," they said. "A randomized trial is needed to directly assess the benefits and harms of short-duration versus longer-duration treatment for male UTI."

A research letter from the same group showed that preoperative urinalysis rarely yields a positive result in predominately male patients undergoing nonurologic surgery. Moreover, physicians usually did not prescribe antibiotics for patients who had positive tests, and when they did, antibiotic therapy was associated with an increased risk of surgical-site infection.

Optimal treatment duration for UTI in women is well defined, but the best treatment duration for men with UTI has yet to be determined.

Current clinical opinion favors a treatment duration of 7 to 14 days, based primarily on a single study of men with febrile UTI, the authors noted. Moreover, that trial compared 14 versus 28 days of therapy and demonstrated equivalence.

"However, no study to date has specifically assessed the adequacy of 7-day therapy for male UTI or has compared 7 with 14 days to determine whether 7 days of treatment is as effective or less toxic," the authors wrote.

Drekonja's group searched records of the Minneapolis VA system for men who had diagnostic codes for UTI in 2009 and linked them to UTI-relevant antibiotic prescriptions.

The search yielded 39,149 episodes of UTI involving 33,336 men. The episodes consisted of 33,336 primary cases, 1,772 early recurrences (<30 days), and 4,041 late recurrences.

In almost two-thirds of infections (62.7%), ciprofloxacin was the antibiotic of choice, followed by trimethoprim-sulfamethoxazole (TMP-SFX, 26.8%).

The data showed that 35% of patients received less than or equal to 7 days of antibiotic therapy, with a 7-day treatment being the most common (77.2%), followed by 5 days (14.2%), and 3 days (6.6%).

Also, 65% continued treatment beyond 7 days, and two-thirds received a 10-day course of antibiotics, followed by 14 days (18.7%), and 30 days (3.7%).

Early recurrence was documented in 4.1% of primary cases, including a single episode of recurrence in 3.9% and multiple recurrences in 0.2%.

Overall, 9.9% of the men had late recurrences, including a single episode in 8.2% of cases and multiple episodes in 1.7%. The median time to early recurrence was 14 days, and median time to late recurrence was 107 days.

The rate of early recurrence did not differ between men who had shorter- versus longer-duration antibiotic therapy (3.9% versus 4.2%, P=0.16).

In addition to being associated with a higher late recurrence rate, longer-duration therapy also increased the risk of C. difficile infection (0.5% versus 0.3%, P=0.02).

The main study limitation was the reliance on administrative data; the authors could not verify that encounters coded as UTI represented patients actually being treated for symptomatic UTI.

In the research letter, the authors described their experience with 1,688 male patients who underwent 1,934 cardiothoracic, orthopedic, or vascular surgery procedures. Orthopedic procedures predominated, accounting for almost 1,300 procedures.

Overall, 25% of patients had preoperative urine culture tests. None of the patients had signs or symptoms of UTI. Bacteriuria was defined as high count (≥100,000 colony-forming units [CFU]/mL) or low count (10,000 to 90,000 CFU/mL).

Preoperative urinalysis revealed bacteriuria in 54 of 489 (11%) patients. Urine culture was associated with a significantly higher rate of postoperative surgical-site infection (17% versus 4%, P<0.001), diarrhea (6% versus 2%, P<0.001), and C. difficile infection (0.6% versus 0%, P=0.02).

The authors found that 16 patients with positive urine cultures received antibiotic therapy, which was prescribed for patients with low-count bacteriuria in half the cases.

Surgical-site infection occurred significantly more often in patients whose UTI was treated (45% versus 14%, P=0.03), including four of eight (50%) treated patients with high-count bacteriuria versus one of 15 (7%) untreated patients (P=0.03).

"These findings suggest that, outside the context of a randomized clinical trial, preoperative screening for and treatment of asymptomatic bacteriuria should be avoided in patients undergoing cardiovascular, orthopedic, or vascular surgery procedures," the authors wrote.

Although neither study demonstrated a causal link between antibiotic therapy and worse outcomes, the publications drew attention to a long-neglected issue, according to the author of an accompanying editorial.

"What both studies can do, and indeed do effectively, is to call into question current treatment practices concerning bacteriuria in men," wrote Barbara Trautner, MD, PhD, of Baylor College of Medicine in Houston.

For the most part, treatment of asymptomatic bacteriuria is unnecessary and might be harmful in terms of C. difficile infection, antibiotic resistance, and unnecessary expenditures, she added.

"We recommend a culture shift in antibiotic prescribing practices for men with bacteriuria from 'more is better' to 'less is more,'" Trautner wrote. "As we continue to explore UTI in the male half of the population, these articles are a timely reminder that standard practice is not always best practice and that critical thinking is required to recognize the difference."

The studies were supported by the Minneapolis Veterans Affairs Health Care System.

Drekonja reported no conflicts of interest. One co-author disclosed relationships with Merck, Rochester Medical, and Synitron.

Trautner reported no conflicts of interest.

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