By Brenda L. Mooney
MINNEAPOLIS – In a rare study that looked at optimal treatment of urinary tract infections (UTI) in men, researchers from the Minneapolis Veterans Health Care System found that treating the condition for more than a week does not appear to reduce risk of recurrence. In fact, they found, when compared with a shorter course of treatment, the longer course can sometimes have some significant downsides.
That study and a related research letter call into question the “more is better” prescribing practices for bacteriuria in men, according to an accompanying commentary.
According to background information in the study, which was published Online First last month by Archives of Internal Medicine, duration of antimicrobial treatment is important because, while insufficient treatment duration can lead to recurrent disease, prolonged treatment can increase costs, promote antimicrobial resistance and heighten risk of Clostridium difficile infection (CDI).
Dimitri M. Drekonja, MD, MS, and colleagues at the Minneapolis VAMC used administrative data from the Veterans Affairs Computerized Patient Record System to evaluate treatment patterns for male UTI among outpatients, assessing the association between treatment duration and outcomes, including recurrence and development of CDI.
Researchers identified 39,149 UTI episodes involving 33,336 unique patients with an average age of 68 years. That included 33,336 index cases (85.2%), 1,772 cases of early recurrences (4.5%) and 4,041 of late recurrences (10.3%).
“We found that two drugs (ciprofloxacin and trimethoprim-sulfamethoxazole) were used to treat most male UTI episodes and that the treatment duration varied substantially within the recommended seven to 14 days (84.4%) and outside of this range (15.6%),” study authors report. “Most important, compared with shorter-duration treatment (≤7 days), longer-duration treatment (>7 days) exhibited no association with a reduced risk for early or late recurrence.”
Ciprofloxacin was used in 62.7% in of cases, while trimethoprim/sulfamethoxazole was used in 26.8% of cases.
Longer duration of treatment was not associated with a reduction in early or late recurrence but was associated with increased late recurrence, 10.8%, compared with shorter-duration treatment, 8.4%. Study results also suggested that C difficile infection risk was higher with longer-duration, 0.5%, compared with shorter-duration treatment, 0.3%.
Overall, researchers suggest their findings “question the role” of longer-duration treatment for male UTI in the outpatient setting and call for randomized trials to compare that to shorter-duration treatment for male UTI.
In the accompanying commentary, Barbara W. Trautner, MD, PhD, of the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, both in Houston, writes that the studies “call into question” current treatment practices.
“We recommend a culture shift in antibiotic prescribing practices for men with bacteriuria from ‘more is better’ to ‘less is more.’ Widespread antimicrobial resistance, appreciation of the human microbiome, outbreaks of CDI [Clostridium difficile infection] and emphasis on cost-effective care discourage the indiscriminate use of antibiotics,” Trautner notes, pointing out that the studies found no clinical benefit of longer course of antibiotics or additional use of preoperative antibiotics.
She says most studies on UTI in outpatients focus on women, especially younger women.
“As we continue to explore UTI in the male half of the population, these articles are a timely reminder that standard practice is not always best practice and that critical thinking is required to recognize the difference,” Trautner concludes.
In general, UTIs are far more common in women, with only about 20% occurring in men, according to statistics from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), a division of the National Institutes of Health in Bethesda, MD.
NIDDK cited VA statistics from 1999 to 2001 stating that the overall prevalence of UTI as a primary diagnosis in veterans seeking outpatient care was 2.3 to 2.48 times greater in women than in men.
The VA information also noted that rates of orchitis generally were higher than either cystitis or pyelonephritis when considered as either the primary or any diagnosis. UTI rates were higher in older men and African-Americans, according to the statistics.