Cochrane for Clinicians
Putting Evidence into Practice
Antibiotics for Recurrent Urinary Tract Infections
This clinical content conforms to AAFP criteria for evidence-based
continuing medical education (EB CME). EB CME is clinical content presented
with practice recommendations supported by evidence that has been
systematically reviewed by an AAFP-approved source. The practice
recommendations in this activity are available online at
http://www.cochrane.org/cochrane/revabstr/AB001209.htm.
The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Michael Schooff, M.D., and Krista Hill, M.D., present a clinical scenario and question based on the Cochrane Abstract, along with the evidence-based answer and a full critique of the abstract.
Clinical Scenario
A 26-year-old woman visits your clinic with dysuria. She is diagnosed with her fourth urinary tract infection (UTI) of the year.
Clinical Question
Should we use prophylactic antibiotics in patients with recurrent UTIs? If so, which antibiotic and schedule are best?
Evidence-Based Answer
Prophylactic antibiotics can reduce the number of recurrent UTIs in nonpregnant women while they are taking the medication (relative risk [RR], 0.21; number needed to treat [NNT], 2). No antibiotic was significantly better than others at decreasing the number of UTIs, and all antibiotics caused side effects such as candidiasis, rash, and nausea in some patients. Postcoital prophylaxis was as effective as daily prophylaxis in young women. Limited evidence suggests that weekly prophylaxis is better than monthly prophylaxis, but the former has not been compared with daily or postcoital prophylaxis.
Cochrane Abstract
Background. UTI is a common health care problem. Recurrent UTI in healthy, nonpregnant women is defined as three or more episodes of UTI during a 12-month period. Long-term antibiotics have been proposed as a prevention strategy for recurrent UTI.
Objectives. To determine the efficacy (during and after) and safety of prophylactic antibiotics used to prevent uncomplicated recurrent UTI in nonpregnant women.
Search Strategy. The authors1 searched MEDLINE (1966 to April 2004), EMBASE (1980 to January 2003), Cochrane Register of Controlled Trials (in the Cochrane Library Issue 1, 2004), and reference lists of retrieved articles.
Selection Criteria. Published randomized controlled trials (RCTs) in which antibiotics were used as prophylactic therapy in patients with recurrent UTI were selected.
Data Collection and Analysis. Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using the random-effects model, and the results were expressed as RR with a 95 percent confidence interval (CI).
Primary Results. Nineteen studies with a total of 1,120 women were eligible for inclusion. Of these, 10 trials with 430 women compared antibiotics with placebo. During active prophylaxis, the rate of microbiologic recurrence per patient-year was 0 to 0.9 in the antibiotic group compared with 0.8 to 3.6 in the placebo group. The RR of having one microbiologic recurrence was 0.21 (95 percent CI, 0.13 to 0.34), which favored antibiotic, and the NNT was 1.85. The RR for clinical recurrences was 0.15 (95 percent CI, 0.08 to 0.28), and the NNT was 1.85. The RR of having one microbiologic recurrence after prophylaxis was 0.82 (95 percent CI, 0.44 to 1.53). The RR for severe side effects was 1.58 (95 percent CI, 0.47 to 5.28); the RR for other side effects was 1.78 (95 percent CI, 1.06 to 3.00), which favored placebo. Side effects included vaginal and oral candidiasis and gastrointestinal symptoms. Eight trials with 513 women compared antibiotics; these trials were not pooled. Weekly prophylaxis with pefloxacin was more effective than monthly prophylaxis. [note: pefloxacin is a fluoroquinolone that is not available in the United States.] The RR for microbiologic recurrence was 0.31 (95 percent CI, 0.19 to 0.52). There was no significant difference in rates of microbiologic recurrence with daily and postcoital ciprofloxacin.
Reviewers' Conclusions. Compared with placebo, continuous antibiotic prophylaxis for six to 12 months reduced the rate of UTI during prophylaxis. After prophylaxis, two studies showed no difference between groups. The treated group had more adverse events. One RCT compared postcoital and continuous daily ciprofloxacin and found no significant difference in rates of UTI, suggesting that postcoital treatment could be offered to woman who have UTI associated with sexual intercourse.
These summaries have been derived from
Cochrane reviews published in the Cochrane Database of Systematic Reviews in
the Cochrane Library. Their content has, as far as possible, been checked with
the authors of the original reviews, but the summaries should not be regarded
as an official product of the Cochrane Collaboration; minor editing changes
have been made to the text (www.cochrane.org).
Practice Pointers
About 40 percent of all women will report having a UTI during their lives.2 Some studies estimate that 20 percent of young women with acute cystitis will develop recurrent episodes.1
Risk factors for developing UTI in women include sexual intercourse, spermicide and diaphragm use, and a history of recurrent UTI.3 Other risk factors include having a first UTI at age 15 or younger and a mother with a history of UTI.4 After menopause, risk factors include cystocele, incontinence, and postvoiding residual urine.5
There are many options for treating recurrent UTI. This review showed that prophylactic antibiotics are better than placebo in reducing the number of recurrences. The NNT to prevent one symptomatic recurrent UTI in one year was 2.2. However, after prophylactic therapy was stopped, rates of recurrence were equal to those in women who did not receive prophylactic therapy. The reviewed studies showed that side effects with the antibiotics were common and included nausea, rash, and oral and vaginal candidiasis. The number needed to harm for any side effect was 13.5.1 Thus, if 14 women are treated with antibiotic prophylaxis for one year, seven will have one fewer recurrent UTI, and one will experience a side effect.
Schedules for management of recurrent UTI include daily, weekly, or monthly prophylaxis, postcoital prophylaxis, and acute self-treatment.6 One study showed that sexually active young women who took postcoital ciprofloxacin had similar outcomes to women who took ciprofloxacin daily. Another study showed that weekly prophylaxis was better than monthly prophylaxis. No studies compared daily and weekly prophylaxis.1
There are various antibiotics to consider in treating recurrent UTI. Antibiotics included in the review were fluoroquinolones, first-generation cephalosporins, trimethoprim, sulfamethoxazole, and nitrofurantoin. The review found that no antibiotic was superior.
Family physicians must weigh the costs versus the benefits when deciding whether to use prophylactic antibiotic treatment in patients with recurrent UTI. The decision to start prophylaxis should be individualized and based on the patient's preferences. Multiple factors must be considered, including the severity of UTI symptoms, cost, hassle, antibiotic resistance, and potential side effects. In patients who prefer not to use antibiotic prophylaxis, well-established protocols are available for empiric treatment by telephone.
REFERENCES
1. Albert X, Huertas I, Pereiró II, Sanfélix J, Gosalbes V, Perrota C. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 2004;(4):CD001209.
2. Kunin CM. Urinary tract infections in females. Clin Infect Dis 1994;18:1-10.
3. Hooton TM, Scholes D, Hughes JP, Winter C, Roberts PL, Stapleton AE, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med 1996;335:468-74.
4. Scholes D, Hooton TM, Roberts PL, Stapleton AE, Gupta K, Stamm WE. Risk factors for recurrent urinary tract infection in young women. J Infect Dis 2000;182:1177-82.
5. Raz R, Gennesin Y, Wasser J, Stoler Z, Rosenfeld S, Rottensterich E, et al. Recurrent urinary tract infections in postmenopausal women. Clin Infect Dis 2000;30:152-6.
6. Orenstein R, Wong ES. Urinary tract infections in adults. Am Fam Physician 1999;59:1225-34, 1237.
Cochrane Briefs
Effects of Discontinuing Epidurals in Late Labor
Clinical Question
Does discontinuing epidural analgesia in the second stage of labor reduce rates of instrumented delivery or change patient satisfaction with labor?
Evidence-Based Answer
Based on three good studies of 462 patients, discontinuing epidural analgesia in the second stage of labor does not significantly change rates of instrumented delivery or other delivery outcomes, but it increases rates of inadequate pain relief.
Practice Pointers
The American College of Obstetricians and Gynecologists1 supports the use of epidural analgesia during labor. The policy states that epidurals should not be denied because of the patient's insurance and that nurses should not be restricted from managing regional anesthesia.1 Because epidural analgesia provides the highest level of pain relief, the physician and patient should decide when it should be used. However, there are concerns that epidural analgesia increases rates of instrumented deliveries. To reduce this risk, physicians sometimes discontinue epidural analgesia during the second stage of labor. Torvaldsen and colleagues reviewed the literature to determine if this practice improves outcomes.
The authors found five studies, three of which were good quality. They did not find a statistically significant difference in rates of instrumented delivery or cesarean delivery, duration of the second stage of labor, low Apgar scores, or fetal malposition at delivery. The only statistically significant difference was an increased rate of inadequate pain relief during the second stage of labor.
Some women may be willing to accept discomfort in the second stage of labor even if the risk of poor outcomes is small. A larger study is needed to determine if there is a difference in outcomes. There is inadequate data to support the practice of discontinuing epidural analgesia in the second stage of labor.
Torvaldsen S, et al. Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia. Cochrane Database Syst Rev 2004;(4):CD004457.
REFERENCES
1. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 295: pain relief during labor. Obstet Gynecol 2004;104:213.
Comparison of Short-Term Treatments for GERD
Clinical Question
Which medications improve outcomes in patients with symptoms of gastroesophageal reflux disease (GERD) who are treated empirically and in those with symptoms but a normal endoscopy?
Evidence-Based Answer
For empiric treatment of GERD or endoscopy-negative reflux disease, a short trial of a proton pump inhibitor increases the chance of remission. Histamine H2-receptor antagonists are less expensive and work well in many patients, particularly those with less severe symptoms or endoscopy-negative reflux disease.
Practice Pointers
GERD is extremely common, and most patients are treated empirically. Endoscopy can diagnose esophagitis, ulcers, bleeding, strictures, Barrett's esophagus, and carcinoma. Urgent upper endoscopy should be performed in patients with melena, hematemesis, persistent vomiting, anemia, acute onset of total dysphagia, or involuntary weight loss of more than 5 percent of total body weight. Patients older than 45 to 50 years should receive nonurgent endoscopy. Younger patients should be considered for endoscopy if they are at risk for gastric cancer.1,2 Pinxeren and colleagues reviewed the literature to determine which treatments benefit patients with symptoms of GERD who are treated empirically, and which options are effective in patients with GERD symptoms but a normal endoscopy.
The authors found 27 trials with 8,402 participants ranging from 18 to 79 years of age (mean age, 48 years); 45 percent of participants were men. Most of the trials were of adequate quality. Patients who were treated empirically had a remission in heartburn when they received proton pump inhibitors (relative risk [RR], 0.37; 95 percent confidence interval [CI], 0.32 to 0.44) and histamine H2-receptor antagonists (RR, 0.77; 95 percent CI, 0.60 to 0.99). In direct comparisons, proton pump inhibitors were significantly more effective than histamine H2-receptor antagonists and prokinetics in achieving remission. No significant differences were noted between proton pump inhibitors and histamine H2-receptor antagonists in patients with endoscopy-negative reflux disease.
The results of this study did not identify differences between proton pump inhibitors (such studies are lacking). Because many patients do well with a histamine H2-receptor antagonist at much lower cost, these drugs still should be considered viable treatment options for many patients. The cost difference between the newest proton pump inhibitor (rabeprazole; $4.50 per day) and generic omeprazole (less than $1 per day) or ranitidine (less than $0.50 per day) is substantial.
Pinxteren B, et al. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2004;(4):CD002095.
The Authors
Michael Schooff, M.D., is associate director of the Clarkson Family Medicine Residency Program in Omaha. He received his medical degree from the Uniformed Services University of the Health Sciences, F. Hébert School of Medicine, Bethesda, Md., and completed a family medicine residency at Womack Army Medical Center, Fort Bragg, N.C.
Krista Hill, M.D., is a second-year family medicine resident at the Clarkson Family Medicine Residency Program. She received her medical degree from the University of Nebraska College of Medicine in Omaha.
Address correspondence to Michael Schooff, M.D., Clarkson Family Medicine, 4200 Douglas St., Omaha, NE 68131 (e-mail: mschooff@nebraskamed.com). Reprints are not available from the authors.
REFERENCES
1. Institute for Clinical Systems Improvement. Dyspepsia and GERD. Bloomington, Minn.: Institute for Clinical Systems Improvement, 2004.
2. Evaluation of dyspepsia. American Gastroenterological Association medical position statement: evaluation of dyspepsia. Gastroenterology 1998;114:579-81.
| Copyright © 2005 by the American
Academy of Family Physicians. |
MEDLINE:
• Citation
More in AFP:
• Cochrane for Clinicians: Putting Evidence into Practice (108)
• Anti-Bacterial Agents (60)
• Antibiotic Prophylaxis (5)
• Urinary Tract Infections (27)