A randomized trial of women in Norway, Sweden, and Denmark has found that ibuprofen is not a suitable alternative to antibiotics for treating uncomplicated urinary tract infections (UTIs).
In the non-inferiority study, published today in PLoS Medicine, researchers from the University of Oslo recruited 383 women who had symptoms of uncomplicated UTI from 16 general practice settings from April 2013 to April 2016. The patients were randomized 1:1 to receive either 600 milligrams (mg) of ibuprofen or 200 mg of pivmecillinam (an antibiotic commonly used to treat UTIs in Scandinavia) for 3 days. All participants (patients, treating physicians, and researchers) were blinded to treatment allocation.
The primary outcome of the trial was the proportion of patients who felt cured by day 4, as reported in patient diaries. Secondary outcomes included duration of symptoms, the proportion of patients needing secondary antibiotic treatment, and cases of kidney infection.
By day 4, only 38.7% of the patients in the ibuprofen group felt cured versus 73.6% in the pivmecillinam group, for an adjusted risk difference of 35% in favor of pivmecillinam, which is outside the requirement for reaching non-inferiority.
The results also showed that the women who received ibuprofen experienced UTI symptoms for a median of 6 days, compared with 3 days for the women in the pivmecillinam group. The ibuprofen group also had a higher symptom burden.
Within 4 weeks of initial treatment, 47% of the patients in the ibuprofen group had one or more secondary antibiotic treatments, compared with 11.2% in the pivemecillinam group. In addition, seven patients in the ibuprofen group (but none in the antibiotic group) developed kidney infections, with five requiring hospitalization.
Seeking alternatives for UTI
Ultimately, more than half of the women who received ibuprofen (53%) recovered from their symptoms without additional antibiotic treatment after 4 weeks' follow-up.
This suggests, the authors write, that some women may benefit from initial symptomatic treatment with ibuprofen and a delayed prescription for antibiotics, a strategy that could help reduce antibiotic use in UTI treatment. But because of the longer duration of symptoms and the risk of complications associated with ibuprofen alone, the researchers concluded that antibiotics remain the best treatment for uncomplicated UTIs
"Initial treatment with ibuprofen could reduce unnecessary use of antibiotics in this group," the authors conclude. "However, until we can identify those women in need of antibiotic treatment to prevent complications, we cannot recommend ibuprofen alone to women with uncomplicated UTIs."
The study is the latest to explore whether non-steroidal anti-inflammatory drugs could be a safe and effective alternative to antibiotics for treating uncomplicated UTI, a condition that is mostly self-limiting but still one of the most common indications for antibiotic treatment and a potential target for antibiotic stewardship.
In a small randomized trial conducted in Germany in 2010, two thirds of women taking ibuprofen for uncomplicated UTIs recovered without taking antibiotics, and symptom resolution and course were similar compared with women who took ciprofloxacin. That led researchers to conclude that ibuprofen may be non-inferior to ciprofloxacin for treating uncomplicated UTIs.
A larger study conducted by the same researchers in 2015 also found that two thirds of women on ibuprofen recovered without antibiotic treatment and received fewer overall antibiotic courses than women treated with fosfomycin. The women treated with ibuprofen, however, had a higher total burden of symptoms and suffered more kidney infections. As a result, the authors concluded that they could not recommend the ibuprofen-first approach.
May 15 PLoS Med study