Which is more important? Antibiotic resistance or pyelonephritis?

200 mg generic Ibuprofen from Safeway grocery store.

As we move inexorably towards the end of antibiotics, antibiotic-sparing approaches to the management of infectious diseases become more and more attractive. A study published recently in the BMJ compared the ‘symptomatic’ treatment of uncomplicated UTI in women in the community using ibuprofen with antibiotic treatment using fosfomycin.

494 women presented at German GP practices with signs of UTI without other symptoms or risk factors that may indicate or predispose complicated UTI were randomised to either 3 days of ibuprofen or fosfomycin. Perhaps unsurpsingly (!), the number of antibiotics given to the patients randomised to the ibuprofen group was significantly lower. However, a compositive measure of symptom burden was higher in the ibuprofen group, and breached the non-inferiority threshold.

One fascinating finding that warrants further investigation is that recurrent UTI was more common in the fosfomycin group. Not sure what a plausible biological mechanism for this would be – but if true, it would strength the cases for a non-antibiotic approach. Another interesting idea was to find a ‘middle ground’ approach based on the urine culture. Here, all women would start on ibuprofen pending their urine culture results and those with a bacteriologically-confirmed UTI would be given antibiotics.

So, which is more important? Antibiotic resistance or pyelonephritis? This really depends on your perspective. On one level, this approach to uncomplicated UTI will be difficult to ‘sell’ to a patient: “take this pill, and your symptoms will be worse and you will more likely to have complications in the short term, whereas take this pill and you will be ‘doing the right thing’ and reducing the burden of antibiotic resistance for generations to come”. However, put another way, 2/3 of the patients treated using ibuprofen recovered without antibiotic treatment. Multiply this by all the uncomplicated UTIs treated with antibiotics in the community, and you have a huge potential saving in terms of antibiotic burden. This apparent dicohotomy reminds me of Dr Nikki Fawcett’s blog last year, and the Parable of the Clinician and the Epidemiologist. From the viewpoint of an individual, antibiotic treatment is usually the best choice in the short term. But from the viewpoint of the general population and years to come, antibiotic treatment should be saved as a last resort.

Although the authors concluded by recommending against an ‘ibuprofen first’ approach, my own view is that this study provides pretty powerful evidence to begin to transition away from antibiotics to ‘symptomatic management’ as a front-line approach for uncomplicated UTI in the community. But I’m an epidemiologist so I would say that.

Image: Wikipedia.

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