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Reducing antibiotic use in uncomplicated urinary tract infections in adult women: a systematic review and individual participant data meta-analysis

Reducing antibiotic use in uncomplicated urinary tract infections in adult women: a systematic review and individual participant data meta-analysis
Reducing antibiotic use in uncomplicated urinary tract infections in adult women: a systematic review and individual participant data meta-analysis

Background: Randomised controlled trials (RCTs) investigated analgesics, herbal formulations, delayed prescription of antibiotics, and placebo to prevent overprescription of antibiotics in women with uncomplicated urinary tract infections (uUTI). Objectives: To estimate the effect of these strategies and to identify symptoms, signs, or other factors that indicate a benefit from these strategies. Data sources: MEDLINE, EMBASE, Web of Science, LILACS, Cochrane Database of Systematic Reviews and of Controlled Trials, and ClinicalTrials. Study eligibility criteria, participants and interventions: RCTs investigating any strategies to reduce antibiotics vs. immediate antibiotics in adult women with uUTI in primary care. Methods: We extracted individual participant data (IPD) if available, otherwise aggregate data (AD). Bayesian random-effects meta-analysis of the AD was used for pairwise comparisons. Candidate moderators and prognostic indicators of treatment effects were investigated using generalised linear mixed models based on IPD. Results: We analysed IPD of 3524 patients from eight RCTs and AD of 78 patients. Non-antibiotic strategies increased the rates of incomplete recovery (OR 3.0; 95% credible interval (CrI), 1.7–5.5; Bayesian p-value (p B) = 0.0017; τ = 0.6), subsequent antibiotic treatment (OR 3.5; 95% CrI, 2.1–5.8; p B = 0.0003) and pyelonephritis (OR 5.6; 95% CrI, 2.3–13.9; p B = 0.0003). Conversely, they decreased overall antibiotic use by 63%. Patients positive for urinary erythrocytes and urine culture were at increased risk for incomplete recovery (OR 4.7; 95% CrI, 2.1–10.8; p B = 0.0010), but no difference was apparent where both were negative (OR 0.8; 95% CrI, 0.3–2.0; p B = 0.667). In patients treated using non-antibiotic strategies, urinary erythrocytes and positive urine culture were independent prognostic indicators for subsequent antibiotic treatment and pyelonephritis. Conclusions: Compared to immediate antibiotics, non-antibiotic strategies reduce overall antibiotic use but result in poorer clinical outcomes. The presence of erythrocytes and tests to confirm bacteria in urine could be used to target antibiotic prescribing.

Analgesics, Antibiotics, Cystitis, Delayed prescription, Erythrocytes, General practice
1198-743X
1558-1566
Kaußner, Yvonne
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Röver, Christian
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Heinz, Judith
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Hummers, Eva
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Debray, Thomas P.a.
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Hay, Alastair D.
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Heytens, Stefan
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Vik, Ingvild
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Little, Paul
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Moore, Michael
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Stuart, Beth
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Wagenlehner, Florian
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Kronenberg, Andreas
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Ferry, Sven
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Monsen, Tor
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Lindbæk, Morten
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Friede, Tim
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Gágyor, Ildikó
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Kaußner, Yvonne
428a3a70-e212-4076-9ba2-7a17a8a953f7
Röver, Christian
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Heinz, Judith
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Hummers, Eva
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Debray, Thomas P.a.
7e61a08d-990d-4653-bd58-6a48d392514c
Hay, Alastair D.
bfae9e44-ae9b-473c-923f-1dea50747023
Heytens, Stefan
78a2aeda-438e-4555-9a7d-8e34e9257b35
Vik, Ingvild
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Little, Paul
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
Moore, Michael
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Stuart, Beth
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Wagenlehner, Florian
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Kronenberg, Andreas
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Ferry, Sven
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Monsen, Tor
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Lindbæk, Morten
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Friede, Tim
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Gágyor, Ildikó
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Kaußner, Yvonne, Röver, Christian, Heinz, Judith, Hummers, Eva, Debray, Thomas P.a., Hay, Alastair D., Heytens, Stefan, Vik, Ingvild, Little, Paul, Moore, Michael, Stuart, Beth, Wagenlehner, Florian, Kronenberg, Andreas, Ferry, Sven, Monsen, Tor, Lindbæk, Morten, Friede, Tim and Gágyor, Ildikó (2022) Reducing antibiotic use in uncomplicated urinary tract infections in adult women: a systematic review and individual participant data meta-analysis. Clinical Microbiology and Infection, 28 (12), 1558-1566. (doi:10.1016/j.cmi.2022.06.017).

Record type: Review

Abstract

Background: Randomised controlled trials (RCTs) investigated analgesics, herbal formulations, delayed prescription of antibiotics, and placebo to prevent overprescription of antibiotics in women with uncomplicated urinary tract infections (uUTI). Objectives: To estimate the effect of these strategies and to identify symptoms, signs, or other factors that indicate a benefit from these strategies. Data sources: MEDLINE, EMBASE, Web of Science, LILACS, Cochrane Database of Systematic Reviews and of Controlled Trials, and ClinicalTrials. Study eligibility criteria, participants and interventions: RCTs investigating any strategies to reduce antibiotics vs. immediate antibiotics in adult women with uUTI in primary care. Methods: We extracted individual participant data (IPD) if available, otherwise aggregate data (AD). Bayesian random-effects meta-analysis of the AD was used for pairwise comparisons. Candidate moderators and prognostic indicators of treatment effects were investigated using generalised linear mixed models based on IPD. Results: We analysed IPD of 3524 patients from eight RCTs and AD of 78 patients. Non-antibiotic strategies increased the rates of incomplete recovery (OR 3.0; 95% credible interval (CrI), 1.7–5.5; Bayesian p-value (p B) = 0.0017; τ = 0.6), subsequent antibiotic treatment (OR 3.5; 95% CrI, 2.1–5.8; p B = 0.0003) and pyelonephritis (OR 5.6; 95% CrI, 2.3–13.9; p B = 0.0003). Conversely, they decreased overall antibiotic use by 63%. Patients positive for urinary erythrocytes and urine culture were at increased risk for incomplete recovery (OR 4.7; 95% CrI, 2.1–10.8; p B = 0.0010), but no difference was apparent where both were negative (OR 0.8; 95% CrI, 0.3–2.0; p B = 0.667). In patients treated using non-antibiotic strategies, urinary erythrocytes and positive urine culture were independent prognostic indicators for subsequent antibiotic treatment and pyelonephritis. Conclusions: Compared to immediate antibiotics, non-antibiotic strategies reduce overall antibiotic use but result in poorer clinical outcomes. The presence of erythrocytes and tests to confirm bacteria in urine could be used to target antibiotic prescribing.

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2022-05-24_UTI-IPD-manuscript_CLM-22-23520_CMI_v1.0 - Accepted Manuscript
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Accepted/In Press date: 14 June 2022
Published date: December 2022
Additional Information: Funding Information: The study was funded by the Federal Ministry of Education and Research (No 01KG1801) ( www.bmbf.de ). The funder was not involved in the study design, data collection, analysis, interpretation, writing the report, or in the decision to submit the paper for publication. Publisher Copyright: © 2022 The Author(s)
Keywords: Analgesics, Antibiotics, Cystitis, Delayed prescription, Erythrocytes, General practice

Identifiers

Local EPrints ID: 469424
URI: http://eprints.soton.ac.uk/id/eprint/469424
ISSN: 1198-743X
PURE UUID: 3217a2aa-801b-446d-be30-a36e804fabce
ORCID for Michael Moore: ORCID iD orcid.org/0000-0002-5127-4509

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Date deposited: 14 Sep 2022 16:50
Last modified: 17 Mar 2024 03:01

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Contributors

Author: Yvonne Kaußner
Author: Christian Röver
Author: Judith Heinz
Author: Eva Hummers
Author: Thomas P.a. Debray
Author: Alastair D. Hay
Author: Stefan Heytens
Author: Ingvild Vik
Author: Paul Little
Author: Michael Moore ORCID iD
Author: Beth Stuart
Author: Florian Wagenlehner
Author: Andreas Kronenberg
Author: Sven Ferry
Author: Tor Monsen
Author: Morten Lindbæk
Author: Tim Friede
Author: Ildikó Gágyor

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