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Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial

BMJ 2015; 351 doi: (Published 23 December 2015) Cite this as: BMJ 2015;351:h6544

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Re: Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial

Authors' reply

We agree with Al-Wali that (if an antibiotic treatment approach was chosen) women should be treated with firt line antibiotics to reduce the emergence of resistance.

In the ICUTI trial we choose fosfomycin as comparator because

- German guidelines on UTI recommend Trimethoprim, Nitrofurantoin and Fosfomycin as first line choices (1).
- In Germany the use of nitrofurantoin is restricted. According to the summary of product characteristics provided by the manufacturer nitrofurantoin is allowed only, “when more effective and less risky antibiotics can not be used”. The consequence is, that nitrofurantoin as first line therapy represents an off-label use.
- ecological risks of an increased use of fosfomycin ("emergence of resistance") were discussed and taken into account during the development of the german guideline. Based on the current evidence in 2011 the experts rated the risk as low.

We further agree with Al Wali that data on local antimicrobial resistance are needed. During the conceptualization of the study the information on resistant rates of causative agents in the german primary care setting were scarce. In the meantime a cross sectional study (2) showed low resistance rates for fosfomycin and nitrofurantoin (4.5%, 2.2%) and intermediate rates for trimethoprim (17.5%).

(1) Wagenlehner, FME., Hoyme U, Kaase M, Fünfstück R, Naber KG, Schmiemann G. „Uncomplicated Urinary Tract Infections“. Deutsches Ärzteblatt International 108, Nr. 24 (Juni 2011): 415–23. doi:10.3238/arztebl.2011.0415.

(2) Schmiemann, G, Gágyor I, Hummers-Pradier E, Bleidorn J. „Resistance Profiles of Urinary Tract Infections in General Practice - an Observational Study“. BMC Urology 12, Nr. 1 (21. November 2012): 33. doi:10.1186/1471-2490-12-33.

Competing interests: No competing interests

19 January 2016
Guido Schmiemann
General Practitioner
Ildikó Gágyor
Bremen University Dpt Health Services Research
Grazer Str. 4 Bremen, Germany