Last week I treated a woman with antibiotics for a UTI. UTI is an extremely common problem in primary care, and is one of the most common infections seen in primary care… accounting for 14% of antibiotics prescribed. Her symptoms were compelling, and indeed, she had mild CVA tenderness .. suggesting that there was more than just lower tract disease. Nonetheless, I didn't want to treat her with antibiotics for any longer than necessary. As we know (examples here , here and here) … this is a complex issue, and one that has been carefully studied. Antibiotic resistance is a growing probelm .. and public education remains necessary
Suggestions for reducing resistance…"there are three main ways to control selection and spread of resistant strains: by (i) reducing the amount of antibacterials used; (ii) using optimal dosages (avoiding underdosing) and treatments of short duration; and (iii) reducing the risk of transmission among young children attending daycare centres or kindergartens.
Is there evidence that a short course is effective in UTI? sure is ..
Short course in Adults: "most antimicrobial agents given for 3 days are as effective as those given for longer duration, and adverse events tend to be found more often with longer treatment. "
So .. I have to consider a number of variables in my decision on how long to treat .. and of course I will recall that I am not the only smart, thoguthful person involved in this situation. The patient is an active participant in the treatment process (how often it seems that we physicians forget this !) …
- I don't want to give her only a 3 day supply (she's got flank pain .. she may need more than 3 days. The studies above were done in "uncomplicated cystitis." Her flank pain means she doesn't meet these criteria)
- I don't want her to take the medications any longer than necessary
- I expect that she'll get better within 7 days. (If she doesn't .. I need to hear from her!)
Considering all of this .. some would write an rx for 7 days and be done with it. Others would even write for 14 without a blink. But maybe she doesn't need 7 or 10 or 14 days. Maybe she needs 3. 3 is better than 7 (is better than 14). We'll get less resistance this way. But how will I know if it's OK to stop before 7 days? I won't. But she will. She knew she needed to come see me in the 1st place .. why shouldn't I trust her to know if she feels better? So I tell her to take the medication for 24 hrs after she feels entirely better. We'll call this the "Sick + 24" duration treatment. I use this sort of prescription in cases where there is either good evidence that antibiotics may not be necessary at all (otitis, sinusitis) or where a short duration is often effective (UTI, cellulitis).
Is there science to this treatment strategy? Not yet. But the rationale is clear, and consistent with the evidence. I could have just as given her a 3 or 5 day course .. and insisted that she "take it all." This sort of paternalistic command has always seemed odd to me. It is now clear that the duration of treatment is often arbitrary. While a 5 day course of antibiotics is standard now for otitis media, many physicians still treat for 10 days based on tradition. If we're going the respect our patients .. shouldn't we be honest about the rationale we're using for our decisionmaking about the duration of treatment?