UTI Treatment in Men: Shorter May Be Better

Larry Hand

December 04, 2012

Antimicrobial treatment longer than 7 days for male urinary tract infection (UTI) may not reduce early or late UTI recurrence compared with shorter treatment and may be associated with an increased risk for Clostridium difficile infection (CDI), according to a study published online December 3 in the Archives of Internal Medicine.

In a related research letter published simultaneously, researchers suggest that preoperative screening for and treatment of bacteruria has no benefit and should be avoided in patients who undergo cardiovascular, orthopedic, or vascular surgeries.

Dimitri M. Drekonja, MD, from the Minneapolis Veterans Affairs (VA) Health Care System in Minnesota, and colleagues analyzed the medical records of 39,149 UTI-related encounters among men using VA outpatient services during fiscal year 2009. From that total, they included 33,336 (85.2%; median age, 67.9 years) index cases (International Classification of Diseases, Ninth Revision, UTI cases combined with relevant antimicrobial prescriptions) in their analysis.

Of the index cases, 1772 (4.5% of all encounters) experienced early recurrences, and 4041 (10.3%) experienced late recurrences. Antimicrobial treatment durations ranged from 1 to 173 days (median, 10 days; interquartile range, 7 - 10 days); 11,666 (35.0%) patients were treated for 7 or fewer days, and 21,670 (65.0%) patients were treated for more than 7 days.

In addition, of the index cases, 1373 (4.1%) experienced early recurrences (median, 14 days; range, 1 - 30 days), 3313 (9.9%) experienced late recurrences (median, 107 days; range, 31 - 364 days), and 237 experienced both early and late recurrences.

Using multivariate logistic regression analysis, the researchers found that treatment duration was not associated with early recurrence (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.90 - 1.14). However, they also found that longer-duration treatment was associated with increased late recurrence compared with shorter treatment (10.8% for >7 days vs 8.4% for ≤7 days; P < .001) and that the association remained significant after multivariate analysis (OR, 1.20; 95% CI, 1.10 - 1.30).

In the multivariate analysis, researchers controlled for age, comorbidity, putative UTI risk factors, the antimicrobial used for treatment, the treatment duration, and history of prior CDI.

"The finding that longer-duration treatment was associated with an increased late recurrence risk in univariate and multivariate analyses was unexpected," the researchers write.

CDI was diagnosed in 144 (0.4%) cases within 90 days of treatment onset, with the interval ranging from 1 to 89 days (mean [SD], 38.7 [26.9] days). Longer treatment was associated with an increased risk for CDI compared with shorter treatment (0.5% vs 0.3%; P = .02) in univariate analysis, but this did not remain significant in multivariate analysis.

"We found that 2 drugs (ciprofloxacin and trimethoprim-sulfamethoxazole) were used to treat most male UTI episodes and that the treatment duration varied substantially within the recommended 7 to 14 days (84.4% of patients) and outside of this range (15.6% of patients)," the authors write.

"These findings question the role of longer-duration treatment for male UTI in the outpatient setting," the researchers conclude.

For the research letter, Dr. Dimitri and colleagues analyzed the records of 1934 procedures in 1688 VA patients (96% men; mean age, 61.8 years) who underwent orthopedic procedures (1291 in 1115 patients), cardiothoracic procedures (331 in 314 patients), and vascular procedures (312 in 259 patients). A preoperative urine culture (UC) was taken from 25% of all patients, varying by procedure (cardiothoracic, 85%; vascular, 48%; and orthopedic, 4%; P < .001).

"Screened patients were older (66.9 vs 60.0 years; P < .001), more frequently male (98% vs 95%; P = .002), and more likely to develop [surgical site infection] (17% vs 4%; P < .001), diarrhea (6% vs 2%; P < .001), and CDI (0.6% vs 0%; P = .02)," the researchers write.

When they compared the 54 patients who had a positive screening in terms of treatment or no treatment, they found that more treated patients developed SSI than nontreated patients (45% vs 14%; P = .03).

"Less Is More"

The researchers conclude, "Our findings document that treatment of preoperative bacteriuria is associated with no benefit. 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."

In an accompanying invited commentary, Barbara W. Trautner, MD, PhD, from the Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas, writes that in light of the fact that most studies of UTI have been of women, and the fact that current guidelines exempt men from treatment recommendations, these 2 studies "stand out in welcome relief.... Both studies address questions about the field of UTI in which the existing literature is insufficient to guide clinical management."

Inherent limitations from the use of International Classification of Diseases, Ninth Revision, codes include a lack of symptom information, whether patients used catheters, and whether UTI was complicated or not, she writes.

Nevertheless, she concludes, "What both studies can do, and indeed do effectively, is to call into question current treatment practices concerning bacteriuria in men," Dr. Trautner continues.

"We recommend a culture shift in antibiotic prescribing practices for men with bacteriuria from 'more is better' to 'less is more,' " she concludes.

Both studies were supported by the Minneapolis VA Health Care System, including the Center for Epidemiological and Clinical Research and the Center for Chronic Disease Outcomes Research. One coauthor of the research letter has received scholarship support from the Infectious Diseases Society of America Medical Scholars Program. One coauthor of both studies reports receiving grants or contracts from Merck, Rochester Medical, and Syntiron. The other authors and Dr. Trautner have disclosed no relevant financial relationships.

Arch Intern Med. Published online December 3, 2012.