Some shorter off-guidelines antibiotic regimens are effective in acute cystitis

  • Kim DK & al.
  • Lancet Infect Dis
  • 1 Sep 2020

  • curated by Liz Scherer
  • Clinical Essentials
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Takeaway

  • A shorter, 3-day treatment regimen of pivmecillinam or single-dose third/fourth-generation fluoroquinolones can effectively treat acute uncomplicated cystitis in women.
  • The authors of this systemic metareview say more data are needed for 3-day nitrofurantoin/trimethoprim and single-dose first/third-generation cephalosporins.

Why this matters

  • A shorter treatment duration than currently recommended in global guidelines could limit adverse events and antibiotic resistance.

Key results

  • 61 trials; 20,780 patients.
  • Pivmecillinam (all values: risk ratios and 95% credible intervals):
    • No significant outcomes difference between 5- and 3-day regimens.
      • Clinical response: 1.041 (0.910-1.193).
      • Microbial response: 1.021 (0.903-1.153). 
    • Also no significant differences between 7- and 3-day regimens.
      • Clinical response: 1.095 (0.999-1.203).
      • Microbial response: 1.058 (0.987-1.145).
  • Co-trimoxazole:
    • 3-day regimen bested single dose for clinical response: 1.147 (1.008-1.309).
    • 3-day was no more effective than single dose for microbial response: 1.023 (0.954-1.102).
  • Fluoroquinolones:
    • 3-day second-generation was more effective than single dose.
      • Clinical response: 1.044 (1.010-1.084).
      • Microbial response: 1.039 (1.003-1.076).
    • 3-day and single dose did not differ with third-generation fluoroquinolones:
      • Clinical response: 0.994 (0.939-1.052). 
      • Microbial response: 1.028 (0.957-1.108).
    • Also no difference between 3-day and single dose with fourth-generation fluoroquinolones:
      • Clinical response: 1.024 (0.974-1.083).
      • Microbial response: 1.031 (0.972-1.094).

Study design

  • Systematic metareview of evidence for shortening internationally recommended treatment duration of antibiotics for acute uncomplicated cystitis in women.
  • Funding: None.

Limitations

  • Inconsistent antibiotic generations, dosing.
  • Different inclusion/exclusion criteria.
  • Outcomes bias.