Are antibiotics for an uncomplicated UTI always necessary?

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Dr. Carrie Aisen is a San Diego-based urologist focused on evidence-based medicine. Dr. Aisen received her MD from Columbia University.

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As I have written about previously, there are many approaches to preventing recurrent urinary tract infections but what are the options for treating active infections? Most people think that all UTIs must be treated with antibiotics. However, there is research suggesting that this is not necessarily the case. UTIs in healthy, premenopausal, nonpregnant women with no history of urinary tract abnormalities are classified as uncomplicated. There is a growing body of research on not treating these UTIs with antibiotics.

While delaying or avoiding antibiotic treatment for uncomplicated UTIs may seem like a novel idea, there are a growing number of experts publishing on this topic and promoting this idea. Dr. Finucane, a professor in the division of geriatric medicine and gerontology at Johns Hopkins, published an article supporting the idea of rethinking the approach to antibiotic treatment of UTIs. He questions the idea that treating all uncomplicated UTIs provides a benefit to the patients (1). Dr. Hooton, a professor of infectious diseases at the University of Miami, writes that acute uncomplicated UTIs rarely progress to pyelonephritis regardless of treatment with antibiotics and the main goal of antibiotic treatment is to rapidly treat the symptoms (2). Dr. Foxman the director of the Center for Molecular and Clinical Epidemiology of Infectious Diseases at the University of Michigan also comments that while antibiotic treatment of UTIs rapidly treats the symptoms, it selects for bacterial resistance and impacts the vaginal and gut flora (3).

A study from Sweden randomized over 800 women with uncomplicated UTIs to different doses of antibiotics or placebo and found that while the antibiotic groups did have a quicker resolution of symptoms and a higher rate of cure, many in the placebo group had clinical resolution of their UTI. In the placebo group at the 8–10 day follow up 25% had clinically resolved their UTI and at the 35–49 day follow up 51% of patients had clinically resolved their UTI. This is compared to 55–64% clinically cured in the antibiotic groups at 8–10 days and 65–72% clinically cured in the antibiotic groups at 35–49 days (4). These researchers also published an analysis of the placebo group making adjustments for drop out and still estimated that at one week 28% had resolution of the UTI and at the end of the full 5–7 week follow up, 37% had resolution of the UTI (5).

Another randomized placebo-controlled study out of Belgium explored this topic. In this study 56 patients had culture-proven UTIs using a cutoff of 100k CFU/mL. After three days, 81% in the nitrofurantoin antibiotic group had resolution of significant bacteriuria compared to 20% in the placebo group but 80% in the nitrofurantoin group vs 44% in the placebo group had symptomatic improvement or cure. At day 7, 74% in the nitrofurantoin group vs. 41% in the placebo group had resolution of significant bacteriuria and 88% in the nitrofurantoin group vs. 54% in the placebo group had improvement or resolution of symptoms. For the patients who had two week follow up, there was no significant difference between the groups in significant bacteriuria or report of symptoms (6).

A study out of Germany compared treatment with fosfomycin antibiotic to symptom management with ibuprofen. They looked at patients with dysuria and urgency, and while they did urinalysis and urine cultures, positive laboratory tests were not required for inclusion. Patients were encouraged to reach out to their general practitioners for any additional required antibiotic courses. Overall the ibuprofen group did report worse symptoms in the first seven days and longer duration of symptoms however they found that ⅔ of the women in the ibuprofen group did not require antibiotic treatment. In the subgroup of patients with a positive urine culture, the ibuprofen group continued to require a lower rate of antibiotic courses with an average of 0.49 antibiotic courses in the ibuprofen group vs 1.18 antibiotic courses in the fosfomycin group (7). These studies suggest that antibiotics help shorten the course of a urinary tract infection, but even with no treatment many UTIs will resolve by themselves.

Two important issues to think about when deciding whether or not treating a UTI with antibiotics is necessary is the concern for progression of an uncomplicated UTI to pyelonephritis (a kidney infection) and the impact the UTI symptoms have on the patients’ lives.

In regards to the first concern, many of the above studies have reported on the rate of development of pyelonephritis. A meta-analysis looking at randomized controlled trials of antibiotics vs placebo for uncomplicated UTIs found no difference between the two groups in regard to development of pyelonephritis (8). Ferry et al found that there were a total of two patients who developed pyelonephritis — one in the antibiotic group and one in the placebo group. This suggests with or without antibiotic treatment there is a small risk of pyelonephritis (4). Christiaens et al reported that one patient in the placebo group developed pyelonephritis (6). Gágyor et al reported 5 cases of pyelonephritis in the ibuprofen group and 1 in the fosfomycin group. This difference was not statistically significant and all of these patients were able to be successfully treated as outpatients (7). An area for future research is to explore if there are indicators for which patients will develop pyelonephritis. Given that the rates of pyelonephritis in all of the studies were very low, it may be difficult to obtain adequate numbers for analysis without significant institutional collaboration.

The second issue addresses quality of life. As the above studies showed, even in the patients whose UTIs resolved with placebo, it took longer for symptoms to resolve. These symptoms can be incredibly debilitating and disruptive to the patients’ lives so this should not be taken lightly. However, if patients are given options to control their symptoms, this may allow the patient to try delaying or avoiding antibiotics. Urinary analgesics such as phenazopyridine or ibuprofen can help improve the symptoms while waiting to see if the UTI clears without antibiotic treatment.

The above data suggests delaying or avoiding antibiotics for UTIs can be a safe and often successful option. A growing number of publications show this idea is gaining traction in the medical field. Many patients may be interested in trying this approach to delay or avoid antibiotic use, if possible. The randomized placebo-controlled trial out of Belgium found that of 166 patients who were seen for UTI symptoms, only 22 declined to participate in the placebo-controlled trial suggesting that patients are open to alternatives to antibiotic treatment (6).

While it is important to consider the adverse effects of deciding not to treat a UTI with antibiotics, it is also important to consider the adverse effects of treating a UTI with antibiotics. With the above studies suggesting that many UTIs will resolve on their own and antibiotic treatment does not change the risk of progression requiring further treatment, this conservative approach should be considered on a case by case basis through shared decision making between the provider and patient.

Note: Dr. Carrie Aisen represents herself as a healthcare professional in this article, and does not necessarily reflect Uqora's views. For example, at Uqora, we always advise you to seek treatment for a UTI from a healthcare practitioner right away. Since UTIs can escalate quickly (and even become life-threatening) at Uqora we legally can't advise anyone to do anything other than speak with a medical professional if they suspect they have a UTI.

1. Finucane ET: ‘Urinary tract infection’ and the microbiome. Am J Med 2017; 130: e97.
2. Hooton TM: Clinical practice. Uncomplicated urinary tract infections. N Engl J Med 2012; 366; 1028.
3. Foxman B: The epidemiology of urinary tract infection. Nat Rev Urol 2010; 7: 653.
4. Ferry SA, Holm SE, Stenlund H et al: Clinical and bacteriological outcome of different doses and duration of pivmecillinam compared with placebo therapy of uncomplicated lower urinary tract infection in women: the LUTIW project. Scand J Prim Health Care 2007; 25: 49
5. Ferry SA, Holm SE, Stenlund H, Lundholm R, Monsen TJ. The natural course of uncomplicated lower urinary tract infection in women illustrated by a randomized placebo controlled study. Scand J Infect Dis. 2004;6:296–301.
6. Christiaens TC, De Meyere M, Verschraegen G et al: Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. Br J Gen Pract 2002; 52: 729.
7. Gágyor I, Bleidorn J, Kochen MM, Schmiemann G, Wegscheider K, Hummers-Pradier E. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial. BMJ. 2015;351:h6544. Published 2015 Dec 23.
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