Short vs. long antibiotic treatment for pyelonephritis and complicated urinary tract infections: a living systematic review and meta-analysis of randomized controlled trials.

BACKGROUND

Reducing antibiotic exposure is desirable.

OBJECTIVES

This study aims to compile evidence on the durations of treatment for pyelonephritis or febrile complicated urinary tract infection (cUTI) in a living systematic review.

METHODS

DATA SOURCES: PubMed, Cochrane Central Register of Controlled Trials, and Web of Science from inception to 30 November 2024, trial registries, and conference proceedings. Living review searches will be updated monthly and the evidence yearly. Updates will be available at https://github.com/LivingSystematicReview/Pyelonephritis-KeepItShort.

STUDY ELIGIBILITY CRITERIA AND

PARTICIPANTS

We included randomized controlled trials involving adults with pyelonephritis or cUTI with systemic signs (mainly fever). The primary outcome was clinical success by day 7 after the end of treatment.

INTERVENTIONS: Different treatment durations within the same antibiotic class or treatment strategy (e.g. physicians' selected, in vitro-matching antibiotics). ASSESSMENT OF RISK OF BIAS: was conducted using the Cochrane risk-of-bias 2.0 tool and certainty of evidence was assessed.

METHODS OF DATA SYNTHESIS: Risk ratios (RRs) were compiled using the fixed effect model. Subgroups of interest were assessed.

RESULTS

Sixteen randomized controlled trials were included, comprising 4643 patients. Treatment durations of 5-7 days vs. 10-14 days were compared in 12 trials. There was some risk-of-bias concern in most trials, mainly because of dropouts and lack of blinding. There was no significant difference between short- and long-treatment durations for clinical success (RR, 1.01; 95% CI, 0.98-1.04; moderate-certainty evidence); 0.97 (0.91-1.04) in men (low-certainty evidence); 1.01 (0.97-1.05) among patients treated with quinolones and 1.01 (0.94-1.08) among patients treated with any (physician-selected or penicillin-based) antibiotic. Similarly, there were no significant differences between short and long-treatment groups in microbiological cure, relapse or reinfection, and adverse events. The mortality analysis comprised 57.2% (2274/3976) patients with bacteraemia; no significant difference was observed between groups (RR, 0.87; 95% CI, 0.68-1.13).

CONCLUSIONS

Treatment durations of 5-7 days for pyelonephritis or febrile cUTI were as effective as longer treatment durations.