Correspondence
Correction
Urinary Tract Infection
N Engl J Med 2003; 349:1674-1676October 23, 2003
- Article
To the Editor:
In the Clinical Practice article by Fihn on acute uncomplicated urinary tract infection in women (July 17 issue),1 the recommendations for treatment appear to be somewhat out of date. First, the expected rates of clinical failure among women treated with trimethoprim–sulfamethoxazole for acute uncomplicated cystitis are now more secure and suggest that fluoroquinolones or nitrofurantoin should be considered first-line treatment in many parts of the United States. In an Israeli study with a 29 percent rate of in vitro resistance to trimethoprim–sulfamethoxazole, the rate of clinical failure was 23 percent overall and 46 percent among patients with pathogens that were resistant to trimethoprim–sulfamethoxazole.2 Second, after the Infectious Diseases Society of America issued its 1999 guidelines for the treatment of urinary tract infection in women with acute uncomplicated pyelonephritis, it was demonstrated that 7 days of ciprofloxacin therapy was superior to 14 days of treatment with trimethoprim–sulfamethoxazole (largely because clinical failure among women treated with trimethoprim–sulfamethoxazole was associated with the 18 percent rate of in vitro resistance to trimethoprim–sulfamethoxazole in a study conducted in the United States between 1994 and 1997).3 These findings have led to the recommendation in annual antimicrobial guidebooks that the former treatment be used.4 Although better surveillance data regarding resistance and studies of quality-of-life and cost outcomes are needed, the days of trimethoprim–sulfamethoxazole as the treatment of choice for uncomplicated urinary tract infection in women may be numbered.
4 ReferencesDavid A. Talan, M.D.
Olive View–UCLA Medical Center, Sylmar, CA 91342
dtalan@ucla.edu 1
Fihn SD . Acute uncomplicated urinary tract infection in women. N Engl J Med 2003;349:259-266
Full Text | Web of Science | Medline2
Raz R ,Chazan Y ,Kennes Y , et al. Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with a high prevalence of TMP-SMX-resistant uropathogens. Clin Infect Dis 2002;34:1165-1169
CrossRef | Web of Science | Medline3
Talan DA ,Stamm WE ,Hooton TM , et al. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis in women: a randomized trial. JAMA 2000;283:1583-1590
CrossRef | Web of Science | Medline4
Gilbert DN, Sande MA, Moellering RC, eds. The Sanford guide to antimicrobial therapy 2003. 33rd ed. Hyde Park, Vt.: Antimicrobial Therapy, 2003:23.
To the Editor:
We were surprised to see that Fihn advocated the use of trimethoprim without a pregnancy test. Fihn mentions that trimethoprim is a known teratogen in animals and that coitus increases the risk of cystitis. Coitus is associated with pregnancy.
At Charing Cross Hospital, we use cephalexin, a second-generation cephalosporin, for the treatment of uncomplicated urinary tract infection in women. Although the cost of trimethoprim itself is lower, the cost of trimethoprim plus a measurement of beta human chorionic gonadotropin is higher than the cost of treatment with 500 mg of oral cephalexin twice daily three days per week. In addition, in our population, there is an 85 percent sensitivity to cephalexin and a 68 percent sensitivity to trimethoprim.
Rachel Hoey, F.R.C.S.
Fey Probst, F.F.A.E.M.
Charing Cross Hospital, London W6 8RF, United Kingdom
rhoey@hhnt.org Author/Editor Response
As advocated by Dr. Talan and discussed in my article, fluoroquinolones and nitrofurantoin are reasonable alternative treatments for acute cystitis when the local rate of resistance to trimethoprim–sulfamethoxazole is high. Dr. Talan cites a study from Israel in which the rate of resistance approached 30 percent and empirical therapy with trimethoprim–sulfamethoxazole achieved a microbiologic cure in only 77 percent of women.1 Higher cure rates would be expected in locales where the rate of resistance is lower. The critical question remains at what level of ambient resistance trimethoprim–sulfamethoxazole should no longer be considered first-line therapy. Le and Miller concluded that prescribing fluoroquinolones became cost effective when resistance reached 22 percent, but they did not take into account the public health concern about promoting resistance to fluoroquinolones.2 In the United States, approximately 10 percent of isolates of Escherichia coli from urine are resistant to fluoroquinolones, and the prevalence is rising.3 More liberal use of these valuable agents could accelerate the emergence of resistance. Drs. Hoey and Probst advocate treatment with cephalexin, citing low rates of resistance in London. Experience with cephalosporins in the United States, however, has been disappointing, with resistance averaging 70 percent nationally.2 Trimethoprim is definitely contraindicated in pregnancy, but a measurement of beta human chorionic gonadotropin will generally be obtained, irrespective of the agent prescribed, if pregnancy is suspected because of the need for closer follow-up. However, treatment with a beta-lactam or a cephalosporin without a pregnancy test may be reasonable in some circumstances.
Dr. Talan also correctly points to the efficacy of a seven-day course of a fluoroquinolone for women with uncomplicated acute pyelonephritis. As his study showed, trimethoprim–sulfamethoxazole is highly effective in women with sensitive organisms, although information on sensitivity is typically unavailable when treatment is initiated.
I also wish to point out an error in my article in the first sentence of the last paragraph on page 261: lines 4 and 5 should have read, “can be safely treated as outpatients if they do not have complicating factors and signs of systemic toxicity,” rather than “if they do not have factors associated with an upper tract or complicated infection or signs of systemic toxicity,” as printed.
3 ReferencesStephan D. Fihn, M.D., M.P.H.
Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108
sfihn@u.washington. edu 1
Raz R ,Chazan B ,Kennes Y , et al. Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with a high prevalence of TMP-SMX-resistant uropathogens. Clin Infect Dis 2002;34:1165-1169
CrossRef | Web of Science | Medline2
Le TP ,Miller LG . Empirical therapy for uncomplicated urinary tract infections in an era of increasing antimicrobial resistance: a decision and cost analysis. Clin Infect Dis 2001;33:615-621
CrossRef | Web of Science | Medline3
Medscape. UTI-zone: resource center. (Accessed October 3, 2003, at http://www.medscape.com/pages/editorial/resourcecenters/public/uti/regions/national.)
- Citing Articles (1)
Citing Articles
1
Amy B. Howell. (2007) Bioactive compounds in cranberries and their role in prevention of urinary tract infections. Molecular Nutrition & Food Research 51:6, 732-737
CrossRef
