Norfloxacin vs. pivmecillinam in the treatment of uncomplicated lower urinary tract infections in hospitalized elderly patients

Pivmecillinam with Amoxicillin/Clavulanic acid as step down oral therapy in febrile Urinary Tract Infections caused by ESBL-producing Enterobacterales (PACUTI)

BACKGROUND

Oral treatment alternatives for febrile urinary tract infections are limited in the era of increasing antimicrobial resistance. We aim to evaluate if the combination of pivmecillinam and amoxicillin/clavulanic acid is non-inferior to current alternatives for step-down therapy in adult patients with febrile urinary tract infection.

METHODS

We plan to perform an investigator-initiated non-inferiority trial. Adult hospitalised patients treated with 1-5 days of intravenous antibiotics for acute febrile urinary tract infection caused by extended spectrum beta-lactamase (ESBL) producing Enterobacterales will be randomised 1:1 to either control (7-10 days of either oral ciprofloxacin 500 mg twice daily or oral trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily or intravenous ertapenem 1 g once daily, depending on sex, drug allergy, glomerular filtration rate and susceptibility testing) or intervention (10 days of pivmecillinam 400 mg three times daily and amoxicillin/clavulanic acid 500/125 mg three times daily). The primary outcome will be clinical cure 10 days (+/- 2 days) after antibiotic treatment completion. Clinical cure is defined as being alive with absence of fever and return to non-infected baseline of urinary tract symptoms without additional antibiotic treatment or re-hospitalisation (for urinary tract infection) based on a centralised allocation-blinded structured telephone interview. We plan to recruit 330 patients to achieve 90% power based on a sample size simulation analysis using a two-group comparison, one-sided alpha of 2.5%, an absolute non-inferiority margin of 10% and expecting 93% clinical cure rate and 10% loss to follow-up. The primary endpoint will be analysed using generalised estimated equations and reported as risk difference for both intention-to-treat and per protocol populations. Patients are planned to be recruited from at least 10 centres in Sweden from 2023 to 2026.

DISCUSSION

If the combination of pivmecillinam and amoxicillin/clavulanic acid is found to be non-inferior to the control drugs there are potential benefits in terms of tolerability, frequency of interactions, outpatient treatment, side effects, nosocomial infections and drive for further antimicrobial resistance compared to existing drugs.

TRIAL REGISTRATION

NCT05224401. Registered on February 4, 2022.

The efficacy of pivmecillinam in oral step-down treatment in hospitalised patients with E. coli bacteremic urinary tract infection; a single-arm, uncontrolled treatment study

Background

The role of oral beta-lactam antibiotics in treating febrile urinary tract infections (UTI) is not yet definite. Today, fluoroquinolones together with trimethoprim–sulfamethoxazole (TMP–MTX) are considered standard of care and often the only available evidence-based oral treatment for febrile UTI. This study clarifies the efficacy and safety of pivmecillinam (PIV) used as step-down therapy for bacteremic urinary tract infection (UTI).

Methods

A single-arm, uncontrolled treatment trial was conducted in the period September 2017–March 2020. Candidates for inclusion were men and women suffering from E. coli bacteremia due to UTI and were consecutively included in a Norwegian hospital. Exclusion criteria were among others: other ongoing bacterial infection, septic shock, pyonephrosis/abscess and pregnancy. After 3 days of parenteral antibiotic, the treatment was converted to the study drug; oral PIV 400 mg QID for 1 week. Primary endpoint was a combination of three elements; afebrility, no need for retreatment and improvement in self-reported health status. Test Of Cure (TOC) was 1 week post-treatment. Secondary endpoints included among others microbiological efficacy and CRP value < 30 mg/L.

Results

Of 476 screened subjects, 53 patients were included. Median age was 67 years, 28 (56%) were women. 50 patients were evaluated for per-protocol analysis. 44 of 50 patients (88%) (95% CI [75.7–95.5]) reached the primary endpoint on TOC. 14 of 48 patients (29.2%) had significant growth (> 10³ CFU/mL) of E.coli on TOC. CRP-level was strongly associated to treatment outcome, (OR 0.006 [95% CI 0.00–0.11], p < 0.001).

Conclusions

This trial documents that PIV 400 mg QID given for 1 week following 3 days of parenteral antibiotics, is a suitable treatment option in patients suffering from bacteremic UTI due to E. coli. Randomised clinical trials studying the efficacy of PIV vs standard of care of febrile UTI are warranted.

Trial registration The trial was registered at ClinicalTrials.gov under the identifier: NCT03282006 13/09/2017 and approved by The Regional Committees for Medical Research Ethics South East Norway (2015/2384/REK sør-øst) and the Norwegian Medicines Agency (SLV; reference No 16/06018-09; EudraCT No 2016-000984-18) before initiation

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07463-7.

Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women

BACKGROUND

Urinary tract infections (UTI) are common in elderly patients. Authors of non systematic literature reviews often recommend longer treatment durations (7 to 14 days) for older women, but the evidence for such recommendations is unclear.

OBJECTIVES

To determine the optimal duration of antibiotic treatment for uncomplicated symptomatic lower UTI in elderly women.

SEARCH STRATEGY

We contacted known investigators and pharmaceutical companies, screened reference lists of identified articles, reviews and books, and searched MEDLINE, EMBASE, CINAHL, Healthstar, Popline, Gerolit, Bioethics Line, The Cochrane Library, Dissertation Abstracts International and Index to Scientific & Technical Proceedings without language restriction. Date of most recent search: 7 May 2008.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing different treatment durations of oral antibiotics for uncomplicated symptomatic lower UTIs in elderly women were included. Whenever possible we obtained outcome data for older women included in studies with a broader age range. We excluded patients with fever, flank pain or complicating factors; studies with treatment durations longer than 14 days and prevention studies.

DATA COLLECTION AND ANALYSIS

The two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random effects model and results expressed as risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

Fifteen studies (1644 elderly women) were included. Three studies compared single dose with short-course treatment (3 to 6 days), six compared single dose with long-course treatment (7 to 14 days) and six compared short- with long-course treatment. Methodological quality of all studies was low except for a more recent geriatric study. There was a significant difference for persistent UTI between single dose and short-course treatment (RR 2.01, 95% CI 1.05 to 3.84) and single versus long-course treatment (RR 1.93, 1.01 to 3.70 95% CI), in the short-term (< 2 weeks post-treatment) but not at long-term follow-up or on clinical outcomes. Patients preferred single dose treatment (RR 0.73, 95% CI 0.60 to 0.88) to long-course treatments, but this was based on one study comparing different antibiotics. Short versus longer treatments showed no significant difference in efficacy. Rate of adverse drug reactions increased significantly with longer treatment durations in only one study.

AUTHORS' CONCLUSIONS

Short-course treatment (3 to 6 days) could be sufficient for treating uncomplicated UTIs in elderly women, although more studies on specific commonly prescribed antibiotics are needed.

Tratamiento de las infecciones no complicadas del tracto urinario inferior

Empirical antibiotic treatment of lower urinary tract infections should be based on the patient's clinical data and on local sensitivity data. Because of the increase in resistance among uropathogens, recommendations on the empirical treatment of urinary tract infections have been modified. Currently, the empirical use of co-trimoxazole, ampicillin, and first-generation cephalosporins and quinolones is not recommended. Fluoroquinolones have been demonstrated to be highly effective in comparative studies but, because of the increase in resistance, the type of patient who can benefit from these antimicrobial agents must be selected. Second- and third-generation cephalosporins still have high sensitivity rates, although the higher recurrence rates associated with their use and the emergence of extended-spectrum beta-lactamase-producing enterobacterial in the community should be taken into account. Amoxicillin-clavulanate is less effective in eradicating infections than quinolones. Fosfomycin-trometamol has resistance rates of below 2% and single-dose therapy has been demonstrated to be safe and effective. Nitrofurantoin is also currently active, although it must be administered for 7 days and can produce toxicity. Both agents are currently recommended as alternative therapeutic options to fluoroquinolones in uncomplicated infections of the lower urinary tract.

The expanding role of fluoroquinolones

There has been a growing rate of resistance among common urinary tract pathogens, such as Escherichia coli, to traditional antimicrobial therapies including the "gold standard" trimethoprim-sulfamethoxazole (TMP-SMX). Consequently, fluoroquinolone antimicrobial agents have taken on an expanding management role for UTIs. In fact, the recent Infectious Diseases Society of America clinical management guidelines for UTI recommend fluoroquinolones as first-line therapy for uncomplicated UTI in areas where resistance is likely to be of concern. Fluoroquinolones have demonstrated high bacteriologic and clinical cure rates, as well as low rates of resistance, among most common uropathogens. There are currently 7 fluoroquinolones with indications for UTI in the United States. However, only 3 are commonly used: levofloxacin, ciprofloxacin, and, to a lesser extent, gatifloxacin. Many of the fluoroquinolone agents have once-daily dosing regimens, enhancing patient adherence. In addition, levofloxacin and gatifloxacin have same-dose bioequivalency between their intravenous and oral formulations, allowing for "switch" or step-down therapy from parenteral to oral formulations of the same agent at the same dose. Fluoroquinolones are indicated for the management of acute uncomplicated UTIs, as well as complicated and severe UTI and pyelonephritis, in adults. They are the first-line treatment of acute uncomplicated cystitis in patients who cannot tolerate sulfonamides or TMP, who live in geographic areas with known resistance >10% to 20% to TMP-SMX, or who have risk factors for such resistance. Fluoroquinolone properties include a broad spectrum of coverage, low rates of resistance, and good safety profiles.

The expanding role of fluoroquinolones

There has been a growing rate of resistance among common urinary tract pathogens, such as Escherichia coli, to traditional antimicrobial therapies including the "gold standard" trimethoprim-sulfamethoxazole (TMP-SMX). Consequently, fluoroquinolone antimicrobial agents have taken on an expanding management role for UTIs. In fact, the recent Infectious Diseases Society of America clinical management guidelines for UTI recommend fluoroquinolones as first-line therapy for uncomplicated UTI in areas where resistance is likely to be of concern. Fluoroquinolones have demonstrated high bacteriologic and clinical cure rates, as well as low rates of resistance, among most common uropathogens. There are currently 7 fluoroquinolones with indications for UTI in the United States. However, only 3 are commonly used: levofloxacin, ciprofloxacin, and, to a lesser extent, gatifloxacin. Many of the fluoroquinolone agents have once-daily dosing regimens, enhancing patient adherence. In addition, levofloxacin and gatifloxacin have same-dose bioequivalency between their intravenous and oral formulations, allowing for "switch" or step-down therapy from parenteral to oral formulations of the same agent at the same dose. Fluoroquinolones are indicated for the management of acute uncomplicated UTIs, as well as complicated and severe UTI and pyelonephritis, in adults. They are the first-line treatment of acute uncomplicated cystitis in patients who cannot tolerate sulfonamides or TMP, who live in geographic areas with known resistance >10% to 20% to TMP-SMX, or who have risk factors for such resistance. Fluoroquinolone properties include a broad spectrum of coverage, low rates of resistance, and good safety profiles.

Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women

BACKGROUND

Urinary tract infections are common in elderly patients. Authors of non systematic literature reviews often recommend longer treatment durations (7-14 days) for older patients than for younger women, but the scientific evidence for such recommendations is not clear.

OBJECTIVES

To determine the optimal duration of antibiotic treatment for uncomplicated symptomatic lower urinary tract infections in elderly women.

SEARCH STRATEGY

We contacted known investigators and pharmaceutical companies marketing antibiotics used to treat urinary tract infections, screened the reference list of identified articles, reviews and books, and searched the following data bases: MEDLINE, EMBASE, CINAHL, Healthstar, Popline, Gerolit, Bioethics Line, The Cochrane Library, Dissertation Abstracts International, Index to Scientific & Technical Proceedings.

SELECTION CRITERIA

All randomized controlled trials in which different treatment durations of oral antibiotics for uncomplicated symptomatic lower urinary tract infections in elderly women were compared. We excluded patients with fever or flank pain and those with complicating factors. Trials with treatment durations longer than 14 days or designed for prevention of urinary tract infection were also excluded. No language restriction was applied.

DATA COLLECTION AND ANALYSIS

The quality of all selected trials was assessed and data extracted by the reviewers. Main outcome measures were persistence of urinary symptoms (short-term and long-term efficacy), effect on mental and functional status and adverse drug reactions. To compare the different treatment durations, we defined the following categories of duration: single dose, short course (3-6 days) and long course (7-14 days). Relative risk (RR) and 95% confidence intervals (CI) were calculated for each trial and outcome and were then combined using a random effects model.

MAIN RESULTS

Thirteen trials were included in this review. Six trials compared single dose with short-term treatment (3-6 days), three studies single dose with long-term treatment (7-14 days) and four trials short-term with long term treatment. Eight trials also included younger patients, but provided a subgroup analysis for elderly women. The methodological quality of all trials was low. All trials reported results of bacteriological cure rate; less often clinical outcomes (e.g. improvement or cure of symptoms) were analyzed. Only five trials compared the same antibiotic given for a different length of time. We performed a separate analysis for these trials. The rate of persistent bacteriuria rate at short-term (two weeks post-treatment) was better in the longer treatment group (3-14 days) than in the single dose group (RR 1.84, 95% CI 1.18 to 2.86). However, the rate of persistent bacteria at long term and the clinical cure rate showed no statistically significant difference between the two groups. Patients showed a preference for single dose treatment (RR 0.73, 95% CI 0.66 to 0.88), however this was based on only one trial comparing the same antibiotic. The comparison of short (3-6 days) and longer treatments (7-14 days) did not show any significant difference, but the number of included studies and sample size were low.

REVIEWER'S CONCLUSIONS

This review suggests that single dose antibiotic treatment is less effective but may be better accepted by the patients than longer treatment durations (3-14 days). In addition there was no significant difference between short course (3-6 days) versus longer course (7-14 days) antibiotics. The methodological quality of the identified trials was poor and the optimal treatment duration could not be determined. We therefore need more appropriately designed randomized controlled trials testing the effect, - on clinical relevant outcomes -, of different treatment durations of a given antibiotic in a strictly defined population of elderly women.

The safety profile of the fluoroquinolones

BACKGROUND

Premarketing trials showed the fluoroquinolone agents to have a favorable side-effect profile, with treatment-related adverse events comprising gastrointestinal, central nervous system, and dermatologic effects that were generally mild and reversible on cessation of treatment. However, postmarketing surveillance studies have identified severe adverse events, including severe anaphylaxis, QTc-interval prolongation, and potential cardiotoxicity, associated with 3 quinolone agents that either resulted in the removal of the agent from the market (temafloxacin and grepafloxacin) or significantly restricted its use due to substantial mortality and morbidity associated with liver toxicity (trovafloxacin). To date, there have been no such significant adverse events associated with the older fluoroquinolone agents, including ciprofloxacin, ofloxacin, norfloxacin, and levofloxacin. However, there are fewer data from postmarketing surveillance studies on the most recently approved agents, such as moxifloxacin and gatifloxacin, or agents awaiting approval, such as gemifloxacin.

OBJECTIVE

This paper examines safety data from the premarketing trials and postmarketing surveillance studies of fluoroquinolones available in the United States.

METHODS

A MEDLINE search was performed to identify all English-language studies published since 1980 concerning the safety profiles of the fluoroquinolones.

CONCLUSIONS

The fluoroquinolone antibacterial agents offer broad-spectrum therapy in patients with a variety of infections. Given similar spectra of activity, the choice between quinolones may be based on differences in efficacy and safety or tolerability profiles. Most drug reactions involving these agents are minor and reversible on discontinuing treatment, but adverse effects can be associated with significant mortality and morbidity, as was seen in the case of trovafloxacin and temafloxacin.

Randomized controlled trials and consensus as a basis for interventions in internal medicine

OBJECTIVES

To estimate the proportion of routine clinical interventions in internal medicine that are supported by the results of randomized controlled trials or consensus amongst experienced internists.

DESIGN

Retrospective review of case records allowed one or more major diagnosis-intervention combination(s) to be identified for each patient. The scientific literature was searched for metaanalyses and randomized controlled trials in electronic databases that supported the specific intervention used. When support from randomized trials was lacking, possible consensus on management was sought by asking national expert panels of experienced clinicians.

SETTING

Department of Medicine at a Swedish teaching hospital.

SUBJECTS

At total of 197 consecutively admitted medical inpatients.

RESULTS

Fifty per cent of the diagnosis-intervention combinations (186/369) were supported by results from randomized controlled trial evidence and 34% (125/369) were supported by consensus amongst experienced clinicians. The proportion of interventions based on randomised controlled trials was highest in patients with cardiac (64%) and other circulatory diagnoses (73%). There were no important differences between sexes or between age groups.

CONCLUSIONS

Half of the interventions used in routine clinical practice amongst medical inpatients are supported by results from randomized controlled trials. These results refute popular claims that only a small proportion of medical interventions are supported by scientific evidence.

The use of oral fluoroquinolones in nursing home patients

The approach to management of patients with presumed infection in the nursing home is influenced by the limited availability of diagnostic tests and support staff. Although antibiotics are most often prescribed in the absence of laboratory data, many studies indicate that empirical therapy for nursing home infections is relatively successful. With the scrutiny on containment of healthcare costs, therapy of nursing home patients has been changing and will continue to shift toward treatment within nursing homes without transfer to a hospital. Better oral antimicrobial agents with a wide spectrum of activity, such as the fluoroquinolones, will play a major role in the treatment of many infections acquired in the nursing home. Because of the favourable characteristics of the fluoroquinolone agents, they should be useful for elderly patients who develop infections in nursing homes. They have excellent in vitro activity against Gram-negative bacteria which are often multidrug-resistant and are common in nursing home patients. Studies indicate that absorption of orally administered fluoroquinolones is very efficient in the elderly and these drugs are well tolerated. Numerous clinical trials have documented good efficacy of the fluoroquinolones in the treatment of elderly patients for the most common infections in the nursing home, including urinary tract infections, respiratory tract infections and skin infections.