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Reappraisal of the treatment duration of antibiotic regimens for acute uncomplicated cystitis in adult women: a systematic review and network meta-analysis of 61 randomised clinical trials

 Do Kyung Kim  ;  Jae Heon Kim  ;  Joo Yong Lee  ;  Nam Su Ku  ;  Hye Sun Lee  ;  Ju-Young Park  ;  Jong Won Kim  ;  Kwang Joon Kim  ;  Kang Su Cho 
 LANCET INFECTIOUS DISEASES, Vol.20(9) : 1080-1088, 2020-09 
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Background: Evidence from numerous randomised clinical trials suggest that shorter-term antimicrobial therapy is as effective as-and has other advantages over-longer-term antimicrobial regimens at achieving symptomatic cure for acute uncomplicated cystitis. Nevertheless, not all shorter regimens are adopted in clinical guidelines. This study was done to reappraise the treatment duration of each antibiotic in current guidelines for acute uncomplicated cystitis to investigate whether the regimen lengths of guideline approved antibiotics could be reduced.

Methods: We systematically searched the PubMed, Embase, and Cochrane Library databases for relevant publications from inception of the databases until Dec 31, 2019. Only randomised clinical trials of women with acute uncomplicated cystitis that assessed antibiotic therapy and reported clinical or microbial response outcome values were included. A network meta-analysis was done and the quality of evidence of all of the included studies was rated. Clinical response was the primary outcome, defined as the complete disappearance of all baseline symptoms at the test-of-cure visit. Bayesian hierarchical random-effects model for dichotomous outcomes was used to compare the efficacy of each antibiotic treatment regimen directly and indirectly. This systematic review is registered in PROSPERO, CRD42018093529.

Findings: Overall, 61 randomised clinical trials-which included 20 780 patients-were assessed in our systematic review. For the third-generation and fourth-generation fluoroquinolones, a 3-day regimen had similar effect to a single-dose regimen for clinical response (risk ratio [RR] 0·994 [95% credible interval 0·939-1·052] vs 1·024 [0·974-1·083]), with moderate quality of evidence. For pivmecillinam, 5-day and 7-day regimens were similar to a 3-day regimen for clinical response, with moderate quality of evidence (RR 1·041 [0·910-1·193] for the 5-day regimen and 1·095 [0·999-1·203] for the 7-day regimen). Meanwhile, for third-generation cephalosporins and amoxicillin and clavulanate, there was no difference between single-dose and 3-day regimens, but quality of evidence supporting this conclusion was low. For second-generation quinolones and co-trimoxazole, single-dose regimen was less effective than 3-day regimen in clinical response, with moderate quality of evidence.

Interpretation: Treatment duration of the third-generation and fourth-generation quinolones and pivmecillinam could be shorter than the currently recommended regimens for acute uncomplicated cystitis. For other antibiotics, shorter duration of regimens could be considered, but further research is needed because of the low quality of supporting evidence.

Funding: None.
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1. College of Medicine (의과대학) > Dept. of Internal Medicine (내과학교실) > 1. Journal Papers
1. College of Medicine (의과대학) > Dept. of Urology (비뇨의학교실) > 1. Journal Papers
1. College of Medicine (의과대학) > Yonsei Biomedical Research Center (연세의생명연구원) > 1. Journal Papers
Yonsei Authors
Ku, Nam Su(구남수) ORCID logo https://orcid.org/0000-0002-9717-4327
Kim, Kwang Joon(김광준) ORCID logo https://orcid.org/0000-0002-5554-8255
Kim, Jong Won(김종원) ORCID logo https://orcid.org/0000-0002-0449-228X
Park, JuYoung(박주영)
Lee, Joo Yong(이주용) ORCID logo https://orcid.org/0000-0002-3470-1767
Lee, Hye Sun(이혜선) ORCID logo https://orcid.org/0000-0001-6328-6948
Cho, Kang Su(조강수) ORCID logo https://orcid.org/0000-0002-3500-8833
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