Fluoroquinolones for the Treatment of Urinary Tract Infection: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines


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Project Line:
Health Technology Review
Project Sub Line:
Summary with Critical Appraisal
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  1. What is the clinical effectiveness of fluoroquinolones for the treatment of urinary tract infections?
  2. What is the cost-effectiveness of fluoroquinolones for the treatment of urinary tract infections?
  3. What are the evidence-based guidelines regarding the use of fluoroquinolones for the treatment of urinary tract infections?

Key Message

Three systematic reviews of critically low quality, nine good-quality randomized controlled trials, one fair-quality randomized controlled trial, one good-quality non-randomized study, six fair-quality non-randomized studies, and nine guidelines were included (one of which was an updated version of another). No economic evaluations were identified. There was evidence for the following fluoroquinolones: ciprofloxacin, gatifloxacin, levofloxacin, lomefloxacin, norfloxacin, rufloxacin, ofloxacin, flerofloxacin, sitafloxacin, and finafloxacin. There was considerable heterogeneity in study design, definition and classification of urinary tract infections (UTIs) among the included studies. In one randomized controlled trial, ceftazidime was more effective than ciprofloxacin in patients with acute obstructive pyelonephritis. However, ertapenem was significantly more effective than fluoroquinolones in complicated UTIs in one non-randomized study. When patients with pyelonephritis or complicated UTIs were considered, sitafloxacin and levofloxacin were similarly effective as ceftrizxone and plazomicin respectively. However, ceftolozane-tazobactam was significantly more effective than levofloxacin in one non-randomized study.In terms of adverse events, there were cases of acute psychosis reported among patients treated with fluoroquinolones, penicillins, or trimethoprim-sulfamethoxazole for UTIs.Based on good to high-quality evidence, the guidelines provide detailed recommendations in the use of fluoroquinolones for the treatment of UTIs.In clinical guidelines, fluoroquinolones are not recommended for children and pregnant women due to the potential adverse effects. A guideline by the National Institute for Health and Care Excellence (NICE) recommends ciprofloxacin for pyelonephritis for non-pregnant women and men aged 16 years and over. In the other three guidelines, both ciprofloxacin and levofloxacin are recommended for acute pyelonephritis.Fluoroquinolones are not recommended as first- or second-line therapy for catheter-associated UTIs or lower UTIs in NICE guidelines. In a German guideline, fluoroquinolones are not recommended for the treatment of acute uncomplicated cystitis in otherwise healthy premenopausal women, unless there is no alternative. Fluoroquinolones are not recommended for uncomplicated cystitis in a European guideline. For recurrent UTIs, there are conflicting recommendations in the guidelines. In a NICE guideline, fluoroquinolones are not recommended for people aged 16 years and over or children under 16 years. However, fluoroquinolones are recommended in a Canadian and a German guideline.