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NSAIDs harmful in treating women with uncomplicated UTI
Clinical Question
Is ibuprofen as effective as antibiotics in managing uncomplicated urinary tract infections in women?
Bottom line
I don't know how this started, but I have seen a handful of studies comparing nonsteroidal anti-inflammatory drugs (NSAIDs) with antibiotics in women with uncomplicated urinary tract infections (UTIs). All of them have found NSAIDs to be inferior to antibiotics. Since this study also found significant harm, can we stop this nonsense now? 1b
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Government
Setting: Outpatient (primary care)
Synopsis
These authors randomly assigned adult, nonpregnant women with uncomplicated urinary tract infections from Scandinavian primary care practices to receive ibuprofen 600 mg 3 times daily (n = 194) or the antibiotic pivmecillinam 200 mg 3 times daily (n = 189). The main outcome, feeling cured by the fourth day, was achieved in only 39% of the ibuprofen-treated women compared with 74% of the women treated with pivmecillinam. Furthermore, all 7 of the women who developed pyelonephritis were treated with ibuprofen. Finally, when the women who received ibuprofen improved, it took a day longer than the women who received antibiotics. Although uncomplicated UTIs in women can be self-limited and resolve without treatment, pyelonephritis is a worrisome complication. Additionally, two-thirds of the women who think they have a UTI are right about it. Since this exceeds the treatment threshold for many clinicians, empiric therapy with antibiotics is quite common. Concerns about antibiotic resistance are legitimate, but this is not the best condition to target. Rather, focusing on reducing antibiotics for colds and other respiratory illnesses and eliminating antibiotics from the food supply are more likely to have a real impact.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Perhaps eliminating antibiotics from the food supply needs more targeted attention / intervention from our Public Health colleagues.
This seems like a no-brainer!
didn't even know that people were recommending NSAID over antibiotics - so glad to know it's inferior anyway and I've been doing the right thing!
If I hear any of my patients suggesting doing this I will intervene immediately.
What's next, use NSAID to treat cancer. But the summary was quite flippant, which was not necessarily the best way to show how ridiculous this notion of treating UTI with NSAID is.
What??!! Glad I am behind the times and have never even heard of such a thing. Happy to not suggest it now either. While antibiotics for UTI may not be inappropriate it may be that we tend to prescribed antibiotics for too long of a course (not just in UTI but others common infections like cellulitis and pneumonia).
Yes! Stop this nonsense now. OTOH, get a tenth of a CME credit
Careful...
Hey folks, remember we are not barbarians and we need to keep an open mind. I fully agree that NSAIDs-only seems silly on the surface HOWEVER, doctors smarter than we have scoffed at many "crazy" ideas over the years only to be eventually proven completely wrong. For example we now treat mild diverticulitis and even appendicitis sometimes conservatively. A lot of invasive ortho procedures are now being shown to be no better than placebo, and every one of you can add something else to the list of medicine's "oops" category. So, while we're all going to continue today with Abx in UTIs as a result of this, we all still need to be respectful and remember to offer kudos to the authors of these articles for testing a theory which very possibly might have revolutionized management of this condition.
Excellent
Options
We should keep in mind that symptom severity varies with acute cystitis and that having options is a good thing. Patients may want to be involved in the decision. In the study almost 40% felt cured by day 4 without antibiotic. As for pyelo, 4% developed it on the NSAID - if we treat for this concern primarily then we are over treating. Treating for reducing duration and severity of symptoms definitely favors antibiotic treatment but if symptoms are milder and patients prefer through informed consent the non antibiotic route should still be a potential option. Especially when we get into the area of recurrent cystitis where frequent antibiotic use occurs we should consider all our options.
Options
We should keep in mind that symptom severity varies with acute cystitis and that having options is a good thing. Patients may want to be involved in the decision. In the study almost 40% felt cured by day 4 without antibiotic. As for pyelo, 4% developed it on the NSAID - if we treat for this concern primarily then we are over treating. Treating for reducing duration and severity of symptoms definitely favors antibiotic treatment but if symptoms are milder and patients prefer through informed consent the non antibiotic route should still be a potential option. Especially when we get into the area of recurrent cystitis where frequent antibiotic use occurs we should consider all our options.
Good poem
This will not change my current management
In my reading Ibuprofen is given not gto treat the infection but to treat the pain