February 24, 2010 — All management strategies for urinary tract infections (UTIs) achieve similar symptom control, according to the results of a randomized controlled trial reported in the February 5 issue of the BMJ.
"Previous studies have documented that delayed antibiotic prescribing in respiratory infections results in good symptom control, reduced belief in the effectiveness of antibiotics, and fewer repeat consultations," write P. Little, from University of Southampton, United Kingdom, and colleagues. "We hypothesised that, compared with an immediate antibiotic prescription, other management strategies would result in worse symptom control, particularly in women asked to delay antibiotics empirically or while waiting for the result of midstream urine analysis. We aimed to assess the effectiveness of management using dipstick or clinical algorithms compared with the alternative management strategies (empirical antibiotic treatment, delayed prescribing, and targeted prescribing based on midstream urine results)."
In a primary care setting, 309 nonpregnant women aged 18 to 70 years seen for suspected UTI were randomly assigned to 1 of 5 different management approaches. These were empiric antibiotics; empiric antibiotics delayed by 48 hours; or targeted antibiotics based on a symptom score (at least 2 of the following features: urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result positive for nitrites or for both leukocytes and blood, or a positive result on midstream urinalysis.
For each group, self-help advice was controlled. Primary study endpoints were symptom severity on days 2 to 4, symptom duration, and antibiotic use.
Women who immediately took antibiotics had 3.5 days of moderately severe symptoms. The 5 groups did not differ significantly in duration or severity of symptoms. Mean frequency of symptoms on a scale of 0 to 6 was 2.15 for immediate antibiotics, 2.08 for midstream urinalysis, 1.74 for dipstick, 1.77 for symptom score, and 2.11 for delayed antibiotics (likelihood ratio test for the 5 groups: P = .177).
However, the percentage of patients using antibiotics differed among the groups (97% in the immediate antibiotic group, 81% in the midstream urine group, 80% in the dipstick group, 90% in the symptom score group, and 77% in the delayed antibiotics group [P = .011]), as did the percentage of patients sending midstream urine samples (immediate antibiotics, 23%; midstream urine, 89%; dipstick, 36%; symptom score, 33%; and delayed antibiotics, 15%; P < .001).
Compared with patients taking immediate antibiotics, those who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.36 - 0.89; P = .014) but, on average, had symptoms for 37% longer (incidence rate ratio, 1.37; 95% CI, 1.11 - 1.68; P = .003). This was especially true for the midstream urine group (73% longer; 95% CI, 22% - 140%), whereas duration was not more than 22% longer in any of the other groups.
Limitations of this study include possible type I error for the subgroup analyses; slight but not significant difference among groups in frequency symptoms at baseline; and some group differentiation in dipstick use, midstream urinalysis, and the willingness of women to delay the use of antibiotics.
"All management strategies achieve similar symptom control," the study authors write. "There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use."
This study was funded by the Health Technology Programme of UK NHS Research and Development. One of the study authors reports having been paid to attend consultancy workshops by Bayer and is currently working in collaboration with Bayer in an unpaid capacity.
BMJ. 2010;340:c199.
source : http://cme.medscape.com/viewarticle/717506?src=cmemp&uac=97984HK
regards, taniafdi ^_^
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