First-Line Antibiotics Remain Best for UTI Treatment

TOPLINE:

First-line antibiotics for uncomplicated urinary tract infection (UTI) remain more effective than fluoroquinolones and beta-lactams, with a 1.78% lower risk for 30-day revisits than fluoroquinolones and a 6.40% lower risk than beta-lactams.

METHODOLOGY:

• A retrospective cohort analysis included 57,585 episodes of UTI among 49,037 female patients (mean age, 51.7 ± 20.1 years) between 2012 and 2021 from Independence Blue Cross claims data in Philadelphia.
• Participants received either first-line antibiotics (nitrofurantoin or trimethoprim-sulfamethoxazole) in 35,018 episodes (61%), fluoroquinolones (ciprofloxacin, levofloxacin, or ofloxacin) in 21,140 episodes (37%), or beta-lactams (amoxicillin-clavulanate, cefadroxil, or cefpodoxime) in 1427 episodes (2%).
• Primary outcome measures included treatment failure, defined as outpatient or inpatient revisit within 30 days for UTI, pyelonephritis, or sepsis, while secondary outcomes assessed risks for gastrointestinal symptoms, rash, kidney injury, and Clostridium difficile infection.
• Analysis utilized machine learning approaches with both domain expert-derived and Observational Medical Outcomes Partnership Common Data Model features to adjust for confounding factors.

TAKEAWAY:

• Compared with fluoroquinolones, first-line antibiotics demonstrated superior efficacy with an absolute risk difference (ARD) of −1.78% (95% CI, −2.37% to −1.06%) for 30-day revisits.
• Compared with beta-lactam antibiotics, first-line treatments showed an ARD of −6.40% (95% CI, −10.14% to −3.24%) for 30-day revisits.
• Adverse events were comparable between treatment groups, though first-line antibiotics showed slightly lower risks for diarrhea (ARD, −0.15%; 95% CI, −0.27% to 0.00%) and acute kidney injury (ARD, −0.35%; 95% CI, −0.52% to −0.18%) than fluoroquinolones.
• Results remained consistent when using both domain expert-derived features and automated Observational Medical Outcomes Partnership feature extraction methods.

IN PRACTICE:

“Using a large, contemporary clinical dataset, we demonstrate that IDSA [Infectious Disease Society of America] guidelines for treatment of uncomplicated UTI remain robust in terms of both effectiveness and adverse events, despite major changes in the epidemiology of antibiotic resistance. Unless a patient has a history of drug resistance or intolerance or lives in a region where local rates of resistance are high, nitrofurantoin and trimethoprim-sulfamethoxazole remain the treatments of choice,” the authors of the study wrote.

SOURCE:

This study was led by Noah Jones, the Massachusetts Institute of Technology in Cambridge, Massachusetts. It was published online on January 31 in JAMA Network Open.

LIMITATIONS:

According to the authors, the study’s cohort showed a lower prevalence of certain comorbidities than the general population, potentially reflecting both the limited scope of data from a single health insurer in Southeast Pennsylvania and the strict inclusion criteria for uncomplicated UTI. Additionally, the researchers noted limited data on patient race, ethnicity, and socioeconomic status, which precluded assessment of treatment effectiveness across diverse subpopulations.

DISCLOSURES:

This study received support from the Independence Blue Cross and the Office of Naval Research (grant NOO014-21-1-2807). Noah Jones reported no relevant conflicts of interest. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.