Although initial treatment of urinary tract infection (UTI) with ibuprofen reduced the use of antibiotics, women had a greater symptom burden and a higher risk of pyelonephritis than those treated with antibiotics from the outset, a primary care study from Germany has found.

A total of 494 women aged 18-65 years, presenting with typical symptoms of UTI were studied.

Of these 246 were randomised to a single dose of fosfomycin 3 g and 248 to ibuprofen (400 mg tds) for three days. Additional antibiotics were subsequently prescribed to patients in both groups for persistent, worsening or recurrent symptoms.

The primary endpoints were the number of antibiotic courses in the first month, and the burden of symptoms in the first week.

The total number of antibiotic courses prescribed in the fosfomycin group was 283 (243 as part of the study; 34 further courses for UTI and six courses for other indications).

The respective number in the ibuprofen group was 94 (81 for UTI and 13 for other reasons). While significantly more women in the ibuprofen group received antibiotics in the follow-up period (21.2%), the total number of antibiotic courses was 64% lower (P < 0.001).

In the ibuprofen group, total symptom burden was higher on days 0-4, and on days 0-7 for all individual symptoms. Symptoms also lasted a day longer, with a mean duration of 5.6 days, in the ibuprofen group. These women also had higher scores for impairment of activity, e.g. restriction of work or regular activities.

Complication rates were higher, with five cases of pyelonephritis in the ibuprofen group compared with one in the fosfomycin group (P = 0.12).

Both groups had similar rates of recurrent UTI.

Two-thirds of the women in the ibuprofen group recovered without antibiotic treatment. However, within a month, 34% of the women in the ibuprofen group received antibiotics for persistent or worsening symptoms compared with 14% in the fosfomycin group.

Although this strategy appears to be successful in reducing antibiotic prescribing, it comes at a cost to the women involved, of more significant symptoms, for a longer duration, with greater impact on their lives and a higher risk of upper urinary tract complications.

Thus, it is difficult to conclude that this approach should be recommended for all women with uncomplicated UTI in primary care.

Most GPs would feel that women presenting with a simple UTI need an antibiotic, and the vast majority of women will leave their appointment with a prescription. Indeed, it is estimated that 25% of antibiotic prescriptions in primary care are for uncomplicated UTI.

The findings from this study clearly suggest that treatment with an NSAID is an option for some patients, perhaps those with less intrusive symptoms, or who have expressed a strong desire to avoid antibiotics where possible.

However, trials in primary care are still needed to look at this strategy in more detail, to assist GPs in deciding the best treatment strategy for individual patients.

Dr Jonathan Rees