Duration of Therapy for Women with Uncomplicated UTI

Clinical Question

What is the most appropriate duration of therapy for uncomplicated urinary tract infections (UTIs) in women?

Evidence-Based Answer

Three days of antibiotic therapy is as effective as longer courses for treatment of uncomplicated UTIs in women.

Practice Pointers

Uncomplicated UTIs in women are one of the most common indications for antibiotics. To prevent resistance, antibiotics should be used judiciously; thus, it is important to determine the minimum duration of antibiotic therapy required for treatment to be effective.

Milo and colleagues reviewed 32 randomized controlled trials (with a total of 9,605 patients) comparing three days of oral antibiotic therapy with longer courses for women 18 to 65 years of age. Pregnant women and women with symptoms that suggest upper UTI (e.g., fever, flank pain, vomiting, positive blood cultures) were excluded.

For short- and long-term resolution of symptoms, the reviewers found no difference between a three-day antibiotic course and a course lasting five to 10 days. Longer courses were more effective at clearing the bacteria on follow-up culture but also caused more adverse effects, and it is not clear that bacterial clearance results in improved patient-oriented outcomes. Although data were limited, organisms cultured were not more likely to be resistant to antibiotics after treatment in either group. For most women, a three-day course of antibiotics is sufficient to treat symptoms.

The Institute for Clinical Systems Improvement (ICSI) guideline1 recommends treatment with double-strength trimethoprim/sulfa-methoxazole (Bactrim DS, Septra DS), one tablet twice per day for three days; or trimethoprim (Proloprim) at a dosage of 100 mg twice per day for three days. For women who are allergic to these first-line medications, the ICSI guideline1 recommends ciprofloxacin (Cipro) at a dosage of 250 mg twice per day for three days, or nitrofurantoin (Macrobid) at a dosage of 100 mg twice per day for seven days. Telephone screening and prescription of treatment is appropriate if there are no complicating factors. In the office, urinalysis is adequate for evaluating symptoms.

Tiotropium Effective in Treatment of COPD

Clinical Question

Is tiotropium (Spiriva) effective for treatment of chronic obstructive pulmonary disease (COPD)?

Evidence-Based Answer

In patients with moderate or severe COPD, tiotropium reduces exacerbations, hospitalizations, and symptom scores and improves health-related quality of life compared with placebo and ipratropium (Atrovent). However, more study is needed to determine tiotropium’s role in the treatment of COPD compared with long-acting beta agonists.

Practice Pointers

The first-line treatment for patients with stable COPD is albuterol (Ventolin).1 For patients whose symptoms are not adequately controlled with albuterol, second-line options include tiotropium, salmeterol (Serevent), formoterol (Foradil), ipratropium, albuterol/ipratropium (Combivent), and levalbuterol (Xopenex). According to the Institute for Clinical Systems Improvement guidelines on COPD,1 tiotropium as a scheduled bronchodilator has significant advantages for patients whose symptoms are not controlled by albuterol.

Tiotropium is a once-daily inhaled selective anticholinergic medication for COPD. It is related to ipratropium but costs around $115 per month, whereas ipratropium (two to four puffs four times per day) costs around $67 per month. Tiotropium may be taken in conjunction with theophylline, steroids, or beta agonists, but it has not been studied with ipratropium. Tiotropium is renally excreted, and dry mouth is the most common adverse effect.

To compare the effectiveness of tiotropium with other treatments, Barr and colleagues reviewed the literature and found nine randomized controlled trials with a total of 6,584 patients. They found that, compared with treatment with placebo or ipratropium, 14 patients must be treated for one year with tiotropium to prevent one COPD exacerbation, and 30 need to be treated to prevent one hospitalization. Tiotropium was more effective than placebo or ipratropium but not more effective than long-acting beta agonists regarding improvement in symptoms or quality of life. There was no statistical difference between exacerbation and hospitalization rates for patients treated with tiotropium compared with long-acting beta agonists.

Tiotropium shows promise as a first-line scheduled bronchodilator, but longer trials and trials comparing tiotropium with long-acting beta agonists are needed.