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Urinary tract infections (UTIs) are among the most common types of bacterial infections.[1] Among individuals younger than age 60, UTIs are much more common in women than in men.[2] But after age 60, the rate of these infections in men begins to approach that seen in women.
As a result, UTIs are a frequent reason for antibiotic treatment. Results of a recent clinical trial published in the July 27, 2021, issue of the Journal of the American Medical Association (JAMA) indicate that in men...
Urinary tract infections (UTIs) are among the most common types of bacterial infections.[1] Among individuals younger than age 60, UTIs are much more common in women than in men.[2] But after age 60, the rate of these infections in men begins to approach that seen in women.
As a result, UTIs are a frequent reason for antibiotic treatment. Results of a recent clinical trial published in the July 27, 2021, issue of the Journal of the American Medical Association (JAMA) indicate that in men with acute UTIs and no fever, a 7-day course of oral antibiotics appears to be just as good for eradicating the infection as the commonly used 14-day course. Importantly, shorter courses of treatment can reduce the risk of adverse effects of antibiotic therapy.
About UTIs
UTIs are infections in any part of the urinary tract, which includes the kidney, ureters (tubes that drain urine from the kidneys to the bladder), bladder and urethra.[3] Bladder infections, known as cystitis, are the most common type of UTI.
UTI symptoms include dysuria (burning or pain when urinating), a persistent urge to urinate, increased urinary frequency, cloudy urine, fever, nausea, vomiting and lower-abdominal or pelvic pain.
In the absence of high fever or signs of severe illness such as sepsis (a life-threatening reaction to infection), UTIs are typically treated with a course of oral antibiotics. For men, the optimal duration of such antibiotic therapy is uncertain. Longer-duration treatment has been hypothesized to result in more complete eradication of the bacteria causing the infection but is associated with more adverse events and the proliferation of antibiotic resistance.[4] Accordingly, treatment guidelines for outpatient management of UTIs generally recommend the shortest duration possible: five to 14 days, based on the specific antibiotic prescribed.[5],[6]
The JAMA trial[7]
Researchers at the Minneapolis and Houston Veterans Affairs (VA) medical centers studied 272 men who had been diagnosed with an acute UTI based on symptoms and already prescribed treatment with either ciprofloxacin (CIPRO) (57% of subjects) or trimethoprim/sulfamethoxazole (BACTRIM, SEPTRA) (43% of subjects) orally for 7 to 14 days. At the time the trial was initiated, 90% of VA outpatients treated for UTIs received one of these antibiotics.
To be eligible for the trial, the antibiotic treatment had to be administered completely or almost completely in the outpatient setting; up to 24 hours of in-hospital observation was permitted. The researchers excluded patients who had a fever (defined as a temperature above 100.3°F) or had been treated for a prior UTI within 14 days. The men enrolled in the trial had a median age of 69 years, with half of the subjects being aged 62 to 73.
The 272 men were randomly assigned in equal numbers to receive their prescribed antibiotic treatment for either 7 or 14 days. Subjects in the 7-day antibiotic group received a placebo for days 8 through 14 of the trial. Both subjects and researchers were blinded to the subjects’ group assignments — a procedure known as “double-blinding” — to minimize the possibility of bias.
The results of the trial revealed no statistically significant difference in treatment effectiveness between the 7-day and 14-day antibiotic treatment regimens. By 14 days after completion of active antibiotic treatment, 93% of those in the 7-day antibiotic group experienced symptom resolution, as did 90% of the 14-day antibiotic group. Subgroup comparisons of treatment duration (7-day versus 14-day) by treatment medication (ciprofloxacin versus trimethoprim/sulfamethoxazole) also found no significant differences, thereby indicating that the choice of medication did not markedly influence the results.
There also was no statistically significant difference in the rate of recurrence of UTI symptoms within 28 days after the study medication was stopped (10% for the 7-day antibiotic group and 13% for the 14-day antibiotic group).
Adverse events occurred in 21% of subjects in the 7-day antibiotic group and 24% of those in the 14-day antibiotic group. The most common adverse events observed in subjects were abnormal blood sugar levels (assessed in 64 of 106 subjects who had diabetes), diarrhea, nausea and headache.
The researchers concluded that a 7-day course of oral antibiotics was not inferior to a 14-day course among men with suspected UTIs and no fever.
What You Can Do
If you have symptoms of a UTI, consult with your doctor. Before beginning an antibiotic to treat a UTI, make sure your doctor tests your urine to confirm the presence of a bacterial infection.[8],[9]
If you need treatment with antibiotics for a UTI, talk to your doctor about minimizing the duration of treatment, but otherwise make sure you take your medication for the full duration as prescribed. For most men with an acute UTI and no fever, a 7-day antibiotic course should be sufficient.
Be aware that because ciprofloxacin (and other fluoroquinolones) carries risks of several disabling and potentially permanent adverse effects, including nerve and brain damage and tendon injury (see the box below for the black-box warning found in the product labeling for ciprofloxacin), it should not be used to treat uncomplicated bladder infections unless there is no other less toxic alternative.
| FDA Black-Box Warning for Ciprofloxacin |
|---|
| WARNING: SERIOUS ADVERSE REACTIONS INCLUDING TENDINITIS, TENDON RUPTURE, PERIPHERAL NEUROPATHY, CENTRAL NERVOUS SYSTEM EFFECTS and EXACERBATION OF MYASTHENIA GRAVIS Fluoroquinolones, including ciprofloxacin, have been associated with disabling and potentially irreversible serious adverse reactions that have occurred together, including:
Fluoroquinolones, including ciprofloxacin, may exacerbate muscle weakness in patients with myasthenia gravis. Avoid fluoroquinolones in patients with a known history of myasthenia gravis. Because fluoroquinolones have been associated with serious adverse reactions, reserve ciprofloxacin for use in patients who have no alternative treatment options for the following indications:
|
References
[1] Foxman B. The epidemiology of urinary tract infection. Nat Rev Med. 2010;7(12):653-660.
[2] Foxman B, Brown P. Epidemiology of urinary tract infections: Transmission and risk factors, incidence, and costs. Infect Dis Clin North Am. 2003;17(2):227-241.
[3] Mayo Clinic. Urinary tract infection (UTI). April 23, 2021. https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447. Accessed November 5, 2021.
[4] Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: Best practice advice from the American College of Physicians. Ann Intern Med. 2021;174(6):822-827.
[5] Ibid.
[6] Hooton TM. Acute simple cystitis in men. UpToDate. October 6, 2021. Accessed November 2, 2021.
[7] Drekonja DM, Trautner B, Amundson C, et al. Effect of 7 vs 14 days of antibiotic therapy on resolution of symptoms among afebrile men with urinary tract infection: a randomized clinical trial. JAMA. 2021;326(4):324-331.
[8] Hooton TM. Acute simple cystitis in men. UpToDate. October 6, 2021. Accessed November 5, 2021.
[9] Hooton TM, Gupta K. Acute complicated urinary tract infections (including pyelonephritis) in adults. UpToDate. March 19, 2021. Accessed November 5, 2021.
