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Effect of 7 vs 14 Days of Antibiotic Therapy on Resolution of Symptoms Among Afebrile Men With Urinary Tract InfectionA Randomized Clinical Trial

Educational Objective
To learn whether the duration of antibiotic treatment influences outcomes in afebrile men with urinary tract infection (UTI).
1 Credit CME
Key Points

Question  Among men with symptoms of urinary tract infection (UTI) who are afebrile, is treatment with ciprofloxacin or trimethoprim/sulfamethoxazole for 7 days noninferior to 14 days of treatment with regard to resolution of UTI symptoms?

Findings  In this randomized clinical trial that included 272 men with presumed symptomatic UTI, resolution of initial UTI symptoms by 14 days after completion of active antibiotic therapy occurred in 122 of 131 (93.1%) participants in the 7-day group and 111 of 123 (90.2%) in the 14-day group, a difference that met the prespecified noninferiority margin of 10%.

Meaning  The findings support the use of a 7-day course of ciprofloxacin or trimethoprim/sulfamethoxazole as an alternative to a 14-day course for treatment of afebrile men with suspected UTI.

Abstract

Importance  Determination of optimal treatment durations for common infectious diseases is an important strategy to preserve antibiotic effectiveness.

Objective  To determine whether 7 days of treatment is noninferior to 14 days when using ciprofloxacin or trimethoprim/sulfamethoxazole to treat urinary tract infection (UTI) in afebrile men.

Design, Setting, and Participants  Randomized, double-blind, placebo-controlled noninferiority trial of afebrile men with presumed symptomatic UTI treated with ciprofloxacin or trimethoprim/sulfamethoxazole at 2 US Veterans Affairs medical centers (enrollment, April 2014 through December 2019; final follow-up, January 28, 2020). Of 1058 eligible men, 272 were randomized.

Interventions  Participants continued the antibiotic prescribed by their treating clinician for 7 days of treatment and were randomized to receive continued antibiotic therapy (n = 136) or placebo (n = 136) for days 8 to 14 of treatment.

Main Outcomes and Measures  The prespecified primary outcome was resolution of UTI symptoms by 14 days after completion of active antibiotic treatment. A noninferiority margin of 10% was selected. The as-treated population (participants who took ≥26 of 28 doses and missed no more than 2 consecutive doses) was used for the primary analysis, and a secondary analysis included all patients as randomized, regardless of treatment adherence. Secondary outcomes included recurrence of UTI symptoms and/or adverse events within 28 days of stopping study medication.

Results  Among 272 patients (median [interquartile range] age, 69 [62-73] years) who were randomized, 100% completed the trial and 254 (93.4%) were included in the primary as-treated analysis. Symptom resolution occurred in 122/131 (93.1%) participants in the 7-day group vs 111/123 (90.2%) in the 14-day group (difference, 2.9% [1-sided 97.5% CI, –5.2% to ∞]), meeting the noninferiority criterion. In the secondary as-randomized analysis, symptom resolution occurred in 125/136 (91.9%) participants in the 7-day group vs 123/136 (90.4%) in the 14-day group (difference, 1.5% [1-sided 97.5% CI, –5.8% to ∞]) Recurrence of UTI symptoms occurred in 13/131 (9.9%) participants in the 7-day group vs 15/123 (12.9%) in the 14-day group (difference, –3.0% [95% CI, –10.8% to 6.2%]; P = .70). Adverse events occurred in 28/136 (20.6%) participants in the 7-day group vs 33/136 (24.3%) in the 14-day group.

Conclusions and Relevance  Among afebrile men with suspected UTI, treatment with ciprofloxacin or trimethoprim/sulfamethoxazole for 7 days was noninferior to 14 days of treatment with regard to resolution of UTI symptoms by 14 days after antibiotic therapy. The findings support the use of a 7-day course of ciprofloxacin or trimethoprim/sulfamethoxazole as an alternative to a 14-day course for treatment of afebrile men with UTI.

Trial Registration  ClinicalTrials.gov identifier: NCT01994538

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Dimitri M. Drekonja, MD, MS, Minneapolis Veterans Affairs Health Care System, 1 Veterans Dr, Mail Code 111F, Minneapolis, MN 55417 (drek0002@umn.edu).

Accepted for Publication: June 1, 2021.

Author Contributions: Dr Drekonja had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Drekonja, Trautner, Amundson, Johnson.

Acquisition, analysis, or interpretation of data: Drekonja, Trautner, Kuskowski, Johnson.

Drafting of the manuscript: Drekonja, Trautner, Amundson.

Critical revision of the manuscript for important intellectual content: Drekonja, Trautner, Kuskowski, Johnson.

Statistical analysis: Kuskowski.

Obtained funding: Drekonja.

Administrative, technical, or material support: Drekonja, Amundson.

Supervision: Drekonja.

Conflict of Interest Disclosures: Dr Trautner reports research and consulting funding from Genentech and the National Institute of Allergy and Infectious Diseases for COVID trials; consultancy fees from Genentech; and grants from the US Department of Veterans Affairs (VA) Rehabilitation Research & Development Service and the Agency for Healthcare Research and Quality. Ms Amundson reports receiving salary support for this trial during the conduct of the study from VA Merit Review grants. Dr. Johnson reports grant support from Allergan/Actavis, Cipla/Achaogen, Melinta, Merck, Shionogi, Synitron, Tetraphase; consulting fees from Crucell/Janssen; and pending patents for 2 E coli strain tests. No other conflicts were reported.

Funding/Support: The study was funded by the VA Merit Review Program, grant number I01BX007080. Dr Trautner’s work is supported in part by a grant from the Houston VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety (CIN 13-413).

Role of the Funder/Sponsor: The funding organization reviewed the design and conduct of the study. The funder had no role in the collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We thank the participants in this trial and the clinicians at the Minneapolis VA Medical Center and the Michael E. DeBakey VA Medical Center in Houston, who referred patients to this study.

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