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Amoxicillin-Clavulanate: Not a Good First-Line Choice for UTIs

Among symptomatic women, the clinical cure rate was lower, and the incidence of side effects was higher, with amoxicillin-clavulanate than with ciprofloxacin.

Clinicians frequently treat acute uncomplicated urinary tract infections (UTIs) empirically, but the standard 3-day course of trimethoprim-sulfamethoxazole has been compromised by the increasing prevalence of resistant organisms. Fluoroquinolones are effective, but resistance to these agents is emerging, and although nitrofurantoin is suggested as a fluoroquinolone-sparing alternative, it requires a 7-day course of treatment. To evaluate the efficacy of another possible alternative, researchers in Washington State randomized 370 symptomatic, healthy, sexually active, nonpregnant women (median age, 22; range, 18-45) to receive 3-day regimens of amoxicillin-clavulanate or the fluoroquinolone ciprofloxacin. Midstream urine and vaginal-swab specimens were collected at enrollment and every 2 weeks for 4 months, or until subjects were treated again for symptomatic persistent or recurrent UTI.

Analyses were limited to 322 women who had at least one follow-up visit. The clinical cure rate was significantly lower in the amoxicillin-clavulanate group than in the ciprofloxacin group (58% vs. 77%), regardless of whether the pathogens were susceptible or resistant to amoxicillin-clavulanate. Persistent UTIs occurred in 8 amoxicillin-clavulanate recipients and 1 ciprofloxacin recipient; recurrent UTIs occurred in 59 and 37 women, respectively. Side effects were reported by 27% of women in the amoxicillin-clavulanate group and 19% in the ciprofloxacin group (P=0.06).

Comment: A 3-day, twice-daily regimen of amoxicillin-clavulanate did not perform well in a head-to-head comparison with ciprofloxacin. Clinicians should continue to prescribe trimethoprim-sulfamethoxazole for women without sulfa allergy, unless the likelihood of resistance is high (based on community resistance rates >20%, or individual risk factors such as recent treatment with TMP/SMX). In the higher-resistance setting, a 3-day course of a fluoroquinolone or a 7-day course of nitrofurantoin is appropriate.

— Jane E. Corboy, MD

Published in Journal Watch Women's Health April 19, 2005

Citation(s):

Hooton TM et al. Amoxicillin-clavulanate vs ciprofloxacin for the treatment of uncomplicated cystitis in women: A randomized trial. JAMA 2005 Feb 23; 293:949-55.

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