Shorter Antibiotic Course OK for UTIs in Men With No Fever

Laird Harrison

August 02, 2021

A week of antibiotics appears just as effective as 2 weeks in treating afebrile men with urinary tract infections (UTIs), researchers say.

Shortening the course of treatment could spare patients side effects from the medications and reduce the risk that bacteria will develop resistance to the drugs, said Dimitri Drekonja, MD, chief of infectious diseases at the Minneapolis VA Medical Center, in Minneapolis, Minnesota.

"You'd like to be on these drugs for as short amount of time as gets the job done," he told Medscape Medical News. The study was published online July 28 in JAMA.

Researchers have recently found that shorter courses of antimicrobials are effective in the treatment of other types of infection and for UTIs in women. However, UTIs in men are thought to be more complicated because the urethra is longer in men than in women.

To see whether reducing length of treatment could be effective in men as well, Drekonja and colleagues compared 7-day and 14-day regimens in men treated at US Veterans Affairs medical centers in Minnesota and Texas.

They recruited 272 men who had symptoms of UTI and were willing to participate. All the men received trimethoprim/sulfamethoxazole or ciprofloxacin for 7 days. Half the men were randomly assigned to continue this treatment for an additional 7 days; the other half received placebo pills for an additional 7 days.

The average age of the men was 69 years. Urine samples were cultured from 87.9% of the men. In 60.7% of these samples, the researchers found more than 100,000 CFU/mL; in 16.3%, they found lower colony counts; and in 23.0%, they found no growth of bacteria. The most common organism they isolated was Escherchia coli.

Results for the two groups were similar. Symptoms resolved 14 days after completion of the course of treatment in 90.4% of those who received 14 days of antibiotics, vs 91.9% of those who received 7 days of antibiotics plus 7 days of placebo pills. At 1.5%, the difference between the two arms was within the predetermined boundary for noninferiority.

The percentage of those who experienced recurrence of symptoms within 28 days of stopping medication was also similar between the two groups. Among those who received 7 days of antibiotics, 10.3% experienced recurrence of symptoms, compared to 16.9% of those assigned to 14 days of antibiotics.

There was no significant difference in the resolution of UTI symptoms between the two groups by type of antibiotic, pretreatment bacteriuria count, or study site.

Adverse events were also similar in the two groups, occurring in 20.6% of the men who received 7 days of antibiotics, vs 24.3% of the men who received 14 days of treatment. In both groups, 8.8% of patients had diarrhea, which was the most common adverse event.

Clinicians should not worry that antibiotic resistance is more likely to develop or that symptoms will recur when patients don't finish a prescribed course of treatment, Drekonja said. "That is an old piece of guidance that has persisted for such a long time," he said. "And it makes all of us in the infectious disease field cringe."

Rather, the current thinking is that the more antibiotics patients take, the more resistance bacteria will develop, he said.

The success of the 7-day regimen raises the question of whether an even shorter course would work equally well. It's not clear how short a course of antibiotics will do the trick. Research in certain populations, such as patients with spinal cord injuries, has suggested that recurrences are more frequent with 3 days of antibiotics than with 14, "so there could be a floor that you do need to go beyond," Drekonja said.

"We're not really sure how much people need," agreed Daniel Morgan, MD, a professor of epidemiology and public health and medicine at the University of Maryland School of Medicine, Baltimore, Maryland, which is why this study is important. "It really defined that 1 week is better than 2 weeks," he told Medscape Medical News.

Another way that clinicians can reduce the use of antibiotics by men with UTIs is to consider alternative diagnoses and to culture urine samples when UTI seems like the most likely cause of their symptoms, said Morgan, who co-authored an accompanying editorial.

He pointed out that the US Food and Drug Administration has issued a black box warning on fluoroquinolones, including ciprofloxacin, because they increase the risk for tendinitis and tendon rupture. Nitrofurantoin and amoxicillin-clavulanate are better alternatives for UTIs, he said.

Even some men with fevers and UTIs may need no more than 7 days of antibiotics, said Morgan. Drekonja said he generally prescribes at least 10 days antibiotics for these men.

The study was funded by the VA Merit Review Program. Morgan and Drekonja have disclosed no relevant financial relationships.

JAMA. Published online July 27, 2021. Abstract, Editorial

Laird Harrison writes about science, health, and culture. His work has appeared in magazines, newspapers, and online publications. He is at work on a novel about alternate realities in physics. Harrison teaches writing at the Writers Grotto. Visit him at lairdharrison.com or follow him on Twitter: @LairdH.

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