Data on fluoroquinolones are compiled from regimens of ofloxacin, norfloxacin, and ciprofloxacin from the referenced clinical trials and not other fluoroquinolones that are no longer commercially available. See text for details.
Data on βlactams data cited are derived from clinical trials examining second and third generation cephalosporins and amoxicillin-clavulanate. See text for details.
Efficacy rates refer to cure rates on the visit closest to a 5–9-day period following treatment, and are averages or ranges calculated from clinical trials discussed in the text.
Estimated clinical efficacy and microbiological efficacy rates should not necessarily be compared across agents, because study design, efficacy definition, therapy duration, and other factors are heterogeneous. Studies represent clinical trials published since publication of the 1999 Infectious Disease Society of America guidelines so as to represent efficacy rates that account for contemporary prevalence of antibiotic-resistant uropathogens. Note that efficacy rates may vary geographically depending on local patterns of antimicrobial resistance among uropathogens. See text for details.
Data on fluoroquinolones are compiled from regimens of ofloxacin, norfloxacin, and ciprofloxacin from the referenced clinical trials and not other fluoroquinolones that are no longer commercially available. See text for details.
Data on βlactams data cited are derived from clinical trials examining second and third generation cephalosporins and amoxicillin-clavulanate. See text for details.
Thus, current randomized clinical trial data provide strong support for consideration of nitrofurantoin as an effective agent for treatment of acute cystitis. Demonstration of efficacy, with minimal drug resistance or propensity for collateral damage, makes nitrofurantoin an attractive agent for cystitis. A 5-day regimen, rather than the traditional 7-day course, can be considered as an effective duration of treatment based on a recent randomized clinical trial .

11. Oral trimethoprim-sulfamethoxazole (160/800 mg [1 double-strength tablet] twice-daily for 14 days) is an appropriate choice for therapy if the uropathogen is known to be susceptible (A-I). If trimethoprim-sulfamethoxazole is used when the susceptibility is not known, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (B-II) or a consolidated 24-h dose of an aminoglycoside, is recommended (B-III).
12. Oral β-lactam agents are less effective than other available agents for treatment of pyelonephritis (B-III). If an oral β-lactam agent is used, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (B-II) or a consolidated 24-h dose of an aminoglycoside, is recommended (B-III).

Background: Uncomplicated urinary tract infections are one of the most common bacterial infections in the United States. Clinical practice guidelines from the Infectious Diseases Society of America recommend nitrofurantoin, trimethoprim-sulfamethoxazole, and Fosfomycin as first-line antibiotic treatments and discourage the use of fluoroquinolone antibiotic agents. US Food and Drug Administration released several black box warnings about fluoroquinolones over the past decade owing to antibiotic resistance and a high burden of adverse events. Historically, uncomplicated urinary tract infections have high rates of guideline-discordant treatment with past studies noting substantial use of fluoroquinolones, directly contradicting clinical practice guidelines.

Objective: This study aimed to assess the current concordance of physician prescribing practices with Infectious Diseases Society of America guidelines for the treatment of uncomplicated urinary tract infections in women and identify patient and physician predictors of guideline concordance.

Study Design: A retrospective observational secondary analysis was conducted using a series of cross-sectional data extracted from the IQVIA (Plymouth Meeting, Pennsylvania) National Disease and Therapeutic Index from 2015 to 2019. An estimated 44.9 million women with uncomplicated urinary tract infections at the age of 18 to 75 years were treated as outpatients. This population was selected to lack relevant comorbidities or urological abnormalities so that it matched the Infectious Diseases Society of America guidelines. The proportion of prescriptions for each antibiotic drug class were reported with 95% confidence intervals and compared with the Infectious Diseases Society of America guidelines. Patient and physician characteristics were included in a multivariate logistic regression model to identify independent predictors of antibiotic selection and thereby guideline concordance.

Results: Of the visits that resulted in antibiotic treatment, the overall concordance rate was 58.4% (26.2 million visits of 44.9 million visits) and increased from 48.2% (3.9 million visits of 8.1 million visits) in 2015 to 64.6% (6.3 million visits of 9.8 million visits) in 2019. The most commonly prescribed antibiotic agents were fluoroquinolones (36.4%, 16.3 million visits of 44.9 million visits), nitrofurantoin (31.8%, 14.3 million visits of 44.9 million visits), and trimethoprim-sulfamethoxazole (26.3%, 11.8 million visits of 44.9 million visits). From 2015 to 2019, fluoroquinolone use decreased whereas nitrofurantoin and beta-lactam use increased. Based on the logistic regression, patients aged 18 to 29 years (odds ratio, 1.60; 95% confidence interval, 1.36-1.88; P<.001) and 30 to 44 years (odds ratio, 1.21; 95% confidence interval, 1.03-1.42; P=.020) had a statistically significantly higher likelihood of receiving guideline-concordant treatment than patients aged 45 to 75 years (reference group). Obstetricians-gynecologists (odds ratio, 3.56; 95% confidence interval, 2.91-4.37; P<.001) and urologists (odds ratio, 3.51; 95% confidence interval, 2.45-5.13; P<.001) had a statistically significantly higher likelihood of concordant treatment than all other specialties combined (reference group).

Conclusion: Guideline discordance continues in the treatment of uncomplicated urinary tract infections with the overuse of fluoroquinolones and the underuse of first-line antibiotic agents. Although improving, continued misuse of antibiotic agents may contribute to the growing rates of antibiotic resistance. Actions such as educating physicians about antibiotic resistance and clinical practice guidelines and providing feedback on prescription habits are needed to increase guideline concordance and therefore reduce the use of fluoroquinolones, especially for physicians in family and internal medicine.

Background: Current guidelines recommend empiric antibiotics as first-line treatment for uncomplicated UTI. Despite proven benefits in treatment, antibiotic resistance rates remain on the rise. This meta-analysis aims to determine whether non-steroidal anti-inflammatory drugs can serve as an effective and safe option in the treatment of uncomplicated lower UTI among non-pregnant women compared to antibiotics.

Methods: A systematic literature search in PUBMED, CENTRAL, and ACP databases from inception to April 2021 was conducted to identify randomized controlled trials that compare the use of non-steroidal anti-inflammatory drugs versus antibiotics in non-pregnant women ≥18 years old with uncomplicated lower urinary tract infection. Primary outcomes were symptom resolution of UTI by Day 3 or 4 of intervention, and upper UTI complications. Secondary outcomes include persistence of positive urine culture despite treatment and need for another rescue antibiotic. Random and fixed-effects model for dichotomous data using Mantel-Haenszel and Peto odds method were reported at 95% CI followed by sensitivity analysis for substantial heterogeneity.

Results: Four RCTs involving 1165 patients were analyzed. The probability of having a symptom resolution by Day 3 or 4 with NSAID use is only less than three-fourths of that with antibiotic treatment (

Rr: 0.69, 95% CIs [0.55, 0.86], p = 0.0008, I = 73%, moderate certainty of evidence). The odds of developing upper UTI complications with use of NSAIDs are 6.49 to 1 for antibiotics (Peto

Or: 6.49, 95% CIs [3.02, 13.92], p < 0.00001, I = 0%, moderate certainty of evidence). Secondary analysis showed that the NSAID group is 2.77x more likely to have persistence of a positive microbiologic urine culture than the antibiotic group (

Rr: 2.77, 95% CIs [1.95, 3.94], p < 0.00001, I = 36%, moderate certainty of evidence). Treatment with NSAIDs are three times more likely to use a secondary or rescue antibiotic due to persistent or worsening symptoms as compared to antibiotics (

Rr: 3.16, 95% CIs [2.24, 4.44], p < 0.00001, I = 47%, low certainty of evidence).

Conclusion: Antibiotic treatment was more effective than use of non-steroidal anti-inflammatory drugs for acute uncomplicated lower urinary tract infection with an overall moderate certainty of evidence.

Purpose Of Review: There is a growing interest in nonantibiotic prevention strategies for recurrent urinary tract infections (rUTIs). Our objective is to provide a focused, pragmatic review of the latest evidence.

Recent Findings: Vaginal estrogen is well tolerated and effective for preventing rUTI in postmenopausal women. Cranberry supplements at sufficient doses are effective in preventing uncomplicated rUTI. Methenamine, d -mannose, and increased hydration all have evidence to support their use, although the evidence is of somewhat variable quality.

Summary: There is sufficient evidence to recommend vaginal estrogen and cranberry as first-line rUTI prevention strategies, particularly in postmenopausal women. Prevention strategies can be used in series or in tandem, based on patient preference and tolerance for side effects, to create effective nonantibiotic rUTI prevention strategies.