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Single-dose ceftriaxone treatment of urinary tract infections
ORIGINAL CONTRIBUTION ceftriaxone, for urinary tract infections; urinary tract infections, treatment
Single.Dose Ceftriaxone Treatment of Urinary Tract Infections Single-dose antibiotic therapy for urinary tract infections in which no underlying structural or neurologic lesions are present holds the promise of greater patient compliance and convenience. We present the results of a study comparing a single intramuscular dose of a long-acting, third-generation cephalosporin, ceftriaxone, with a standard, five-day regimen of trimethoprim-sulfamethoxazole (TMS). Fifty-two patients were entered into the study. After randomization, 26 were assigned to the TMS group and 26 were assigned to the ceftriaxone group. Of the patients who completed the study, 13 of the TMS group had positive cultures at the time of initial presentation, and 20 of the ceftriaxone group had positive cultures. There was no statistical difference between the groups in symptoms of dysuria, hematuria, frequency, flank pain, and nocturia (~ = .05). The physical parameters of age, blood pressure, pulse, and temperature were similar in the two groups (~ = .05), as were the types of infecting organisms (~ = .05). When comparing the two regimens, the ceftriaxone group cure rate (18 of 20, 90%) was not found to be significantly different from that of the TMS-treated control group (13 of 13) (~ = .05). [Rosenberg JM, Levy RC, Cicmanec JF, Hedges JR, Burke BM: Single-dose ceftriaxone treatment of urinary tract infections. Ann Emerg Med October 1985;14:970-972.] INTRODUCTION Patients with uncomplicated urinary tract infections (UTI)I often present to the ED. Single-dose antimicrobial therapy offers an attractive ahemative to the traditional five-to-ten-day antimicrobial course. Our study was undertaken to determine the efficacy of single-dose, intramuscular ceftriaxone compared to a five-day course of oral trimethoprim-sulfamethoxazole in women with uncomplicated UTI. Although other single-dose regimens have proven to be efficacious for this purpose, ceftriaxone has not been tested. Ceftriaxone, a new cephalosporin with prolonged biological half-life of eight hours and extended antibacterial coverage, has shown promise for the treatment of serious clinical infections.
Jack M Rosenberg, M D * Richard C Levy, MD* John F Cicmanec, PhDt Jerris R Hedges, MD* Barbara M Burket Cincinnati, Ohio From the Department of Emergency Medicine* and the Division of Urology,t University of Cincinnati Medical Center, Cincinnati, Ohio. Received for publication June 30, 1984. Revision received November 20, 1984. Accepted for publication March 27, 1985. Presented at the University Association for Emergency Medicine Annual Meeting in Louisville, Kentucky, May 1984. Address for reprints: Jack M Rosenberg, MD, Department of Emergency Medicine, University of Cincinnati Medical Center, 234 Goodman Street, Cincinnati, Ohio 45267.
METHODS Physicians working in the Center for Emergency Care at the University of Cincinnati were asked to enroll into the study female patients with initial laboratory and clinical symptoms suggestive of a urinary tract infection. Exclusion criteria included prior antibiotics; allergies to sulfa, trimethoprim, penicillins, or cephalosporins; pregnancy; medical complications (eg, diabetes); history of frequent UTI; urethral strictures; catheterizations or other recent instrumentation; and age less than 18. All patients enrolled in this study were treated according to a protocol approved by the University of Cincinnati Medical Center Committee on Human Research (institutional review board for human experimentation). Clinical evaluation involved careful history-taking with particular emphasis on presenting symptomatology and physical findings. The patients were asked to rate on an increasing integral scale of zero to four the degree of dysuria, flank pain, hematuria, nocturia, and frequency they experienced prior to ED presentation. Initial laboratory evaluation included urine analysis and midstream clean catch or straight catheterized culture and sensitivity. Symptomatic patients with a single-organism bacterial count of 10s or more
14:10 October 1985
Annals of Emergency Medicine
970/71
SINGLE-DOSE CEFTRIAXONE Rosenberg et al
TABLE. Results of other single-dose therapy trials
Anti biotic Amoxycillin Kanamycin Doxycycline Cephamandole Trimethoprim-sulfamethoxazole
Dosage 3 g 0.5 g 0.3 g 1 g 1.92 g
were said to have UTI. After written informed consent was obtained, the patients were entered into the study and randomized into two groups. One group received a single 500-mg i n t r a m u s c u l a r dose of ceftriaxone, reconstituted in 1% lidocaine to m i n i m i z e discomfort. The other group received a five-day oral regimen of trimethoprim 200 mg/sulfamethoxazole 800 mg (TMS) every 12 hours. Patients who received ceftriaxone were instructed to return for reexa m i n a t i o n after 24 hours and again five to nine days after treatment. A urine sample for culture and sensitivity was obtained at both follow-up visits. Patients who received TMS were asked to return after 48 to 72 hours, at the completion of therapy, and at five to nine days after therapy. As in the ceftriaxone group, urine cultures were obtained at each visit. Monetary incentive for enhancing compliance was provided; patients in both groups received $30 for c o m p l e t i o n of the study. P a t i e n t s were q u e s t i o n e d a b o u t symptoms and drug tolerance at both return visits. Cure was defined as relief of initial symptoms and a sterile urine throughout the follow-up period. Failure was defined as persistence or recurrence of the infection with the same organism by urine culture or the nonresolution of the presenting symptomatology. Statistical analysis of the discontinuous data between groups was performed using chi-square analysis with correction for continuity. Analysis of the continuous data was done using a two-tailed t test. Differences between groups were considered significant at the P = .05 level.
RESULTS Six hundred ninety-one unselected 72/971
Follow-up 1 week 1 week 1 week 1 week 8 to 12 days
No. Cures/Patients 27/35 16/37 37/45 37/53 12/15
female patients presented to the ED with clinical symptoms suggestive of a urinary tract infection during the study period. Fifty-two patients (8%) were entered into the study by physicians working in the Center for Emergency Care. Twenty percent of the pat i e n t s w e r e e x c l u d e d b e c a u s e of medical complications; 14% were currently on medications; 13% were allergic to the study drugs or closely related compounds; 10% were pregnant; 3% had complicated urinary tract infections; in 1% the ED residents were unaware of the study; and 3% were excluded due to other causes. Docum e n t a t i o n was not available to explain the exclusion of 28% of the patients. One patient was dropped from the study when it was subsequently determined that she had a history of recurrent UTI. The patients were randomized to either the TMS or ceftriaxone group. Of the 26 patients in the TMS group, five did not return for follow-up, and eight did not have significant bacteriuria on initial culture, leaving 13 subjects for full evaluation. In the ceftriaxone group two did not return for follow-up and four did not have significant bacteriuria. T h u s 20 patients were available for evaluation. There was no difference in compliance between the two groups. (X2 = 0.58) Escherichia coli was the infecting o r g a n i s m in 27 of the 52 p a t i e n t s (73%) who were enrolled in the study; staphylococcal species, in six (16%); Proteus, in two (5%); Klebsiella, in one (3%); and m i x e d flora, in one (3%). Growth of fewer than l0 s colonies was seen in 15 patients. N o significant difference in the organisms was seen between the two groups. There was no significant difference between the groups with regard to their degree of dysuria, frequency, hematuria, flank pain, or nocturia. The groups also were comparable in Annals of Emergency Medicine
Authors Bailey, Abbott (1976, 1977) Lubis et al (1979) Bailey (1980) Shaw et al (1980) Russ et al (1980)
m e a n p r e s e n t i n g age, t e m p e r a t u r e , blood pressure, and pulse. In the TMS group, all 13 of the compliant patients with a culture-positive UTI were cured by both clinical and bacteriologic criteria. In the ceftriaxone group, 18 patients were cured bacteriologically and clinically. One of the two p a t i e n t s w h o s e t r e a t m e n t failed had slowly abating symptoms and was placed on arnpicillin despite a sterile urine after 48 hours. The other ceftriaxone patient's urine was sterile 24 hours posttherapy, but she was reinfected at nine days by the same o r g a n i s m , w h i c h was r e s i s t a n t to ceftriaxone. This patient returned to thc urology clinic and was treated with ampicillin. Therefore 18 of 20 patients (90%) were cured by a single intramuscular injection of ceftriaxone. N o difference existed b e t w e e n the TMS and ceftriaxone cure rates. Typetwo error at the 60% difference level equaled 0.16. No complaints of adverse reactions were seen in the ceftriaxone group. In the TMS group one patient had a vaginal rash that resolved with discontinu a n c e of the m e d i c a t i o n . A n o t h e r woman left the study after developing gastrointestinal distress.
DISCUSSION Uncomplicated urinary tract infections are c o m m o n in the female population. Single-dose therapy has been advocated as a safe and effective alternative to a five- to 14-day antibiotic regimen. It offers the advantages of assured compliance, lower cost, and fewer side effects. 2 Our study suggests that single-dose ceftriaxone may be as effective as conventional therapy and offers the theoretical advantages of fewer side effects and greater compliance. T h i s l a t t e r b e n e f i t is especially i m p o r t a n t w h e n poor compliance is anticipated. Uncomplicated urinary tract infec14:10 October 1985
tions are t h o u g h t to be s u p e r f i c i a l bladder m u c o s a l i n f e c t i o n s t h a t are usually limited to the transitional epithelium, z Spontaneous cure is possible, b u t t h e u s e of a n t i b i o t i c s improves t h e c h a n c e of a f a v o r a b l e outcome. 1 Recent investigations have focused on the establishment of m i n i m u m effective doses for various antibiotic regimens. Several single-dose r e g i m e n s have been tried with differing success rates (Table).a The variable cure rate in t h e s e s t u d i e s , a s i d e f r o m t h e variability of t h e a n t i m i c r o b i a l agents, might be explained by the inclusion of upper UTI in some studies and the exclusion of resistant infections in other studies. Ceftriaxone,3, 4 a new third-generation cephalosporin w i t h an extended biological half-life, is active against a wide array of bacteria, including those likely to be encountered in an uncomplicated UTI. In our study, initial steri l i z a t i o n of t h e u r i n e was a c c o m plished in all patients, and all bacteria were initially sensitive to ceftriaxone. Our s t u d y was l i m i t e d to w o m e n with uncomplicated lower urinary tract infections who met specific clinical and laboratory criteria. T h e enrollment of patients into this study was a result of the efforts of residents assigned to our ED. To p e r m i t rigid comparison between treatment groups, upper urinary tract infections and infections of less than 10s bacteria per m i l l i l i t e r of urine were excluded from the study. The laboratory criteria of more than 10s bacteria per milliliter
14:10 October 1985
h a s b e e n s h o w n to m i s s a p p r o x i m a t e l y 3 3 % of t h e s y m p t o m a t i c w o m e n w h o actually have a UTI as established by suprapubic aspiration.S,6 Against a c o m m o n array of microorganisms,6 these antibiotic regimens demonstrated no significant difference in cure rate, although the study had a large type-two error. That is, there is considerable potential error in assuming that the two therapies are equivalent w h e n we were unable to detect a statistical difference. The inclusion of m o r e p a t i e n t s in a s i m i l a r s t u d y is n e e d e d to r e d u c e t h e p o t e n t i a l for such an error. In p a t i e n t s in w h o m s i n g l e - d o s e therapy failed, studies have indicated that such patients are candidates for a m o r e e x t e n s i v e w o r k - u p to e x c l u d e a n a t o m i c a l a b n o r m a l i t i e s . l Failure of single-dose therapy has not been reported to progress to acute pyelonephritis or bacteriemia, but no clinical series have studied this event. Does single-dose therapy of uncomplicated UTI cause an increase in recurrent infection rates? In our study one patient had recurrence of the initial infection by the d e v e l o p m e n t of resistance to ceftriaxone. Whether recurrent infections developed in other patients beyond the five- to nine-day f o l l o w - u p v i s i t is u n k n o w n , a n d should be studied.
CONCLUSION In the ED, the clinician treating unc o m p l i c a t e d u r i n a r y tract infections
Annals of Emergency Medicine
often starts therapy immediately w h i l e c u l t u r e s and s e n s i t i v i t i e s are pending. The experimental drug c e f t r i a x o n e in a single dose is suggested in our study to be a safe and efficacious therapy for uncomplicated UTI. As a study drug, no cost comp a r i s o n s c a n be m a d e . B e c a u s e of ceftriaxone's extended a n t i m i c r o b i a l coverage, long biological half-life, and limited n u m b e r of side effects, further research on this drug and the singledose regimen is warranted.
REFERENCES 1. Kunin CM: Detection, Prevention and Management of Urinary Tract Infections. Philadelphia, Lea and Febiger, 1979. 2. Bailey RR: Single Dose Therapy of Urinary Tract Infection. Boston, ADI8 Health Science Press, 1983. 3. Keenholtz SL, Jacobus NV, Tally FP, et al: In vitro activity of RO 13-9904 and GR 20263. Abstracts of 21st Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, Ilinois, 1981, No. 386. 4. Patel IH, Parsonnet M, Weinfeld R: Single p h a r m a k i n e t i c s and t o l e r a n c e of ceftriaxone following intramuscular administration in water or lidocaine. Abstracts of 21st Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, Illinois, 1981, No. 390. 5. Kormaroff AL: Acute dysuria in women. N EngI J Med 1984;310:369. 6. Stamm WE, Counts GW, Running KR, et al: Diagnosis of coliform infection in acutely dysuric women. N Engl J Med 1982;307:463-466.
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Single.Dose Ceftriaxone Treatment of Urinary Tract Infections Single-dose antibiotic therapy for urinary tract infections in which no underlying structural or neurologic lesions are present holds the promise of greater patient compliance and convenience. We present the results of a study comparing a single intramuscular dose of a long-acting, third-generation cephalosporin, ceftriaxone, with a standard, five-day regimen of trimethoprim-sulfamethoxazole (TMS). Fifty-two patients were entered into the study. After randomization, 26 were assigned to the TMS group and 26 were assigned to the ceftriaxone group. Of the patients who completed the study, 13 of the TMS group had positive cultures at the time of initial presentation, and 20 of the ceftriaxone group had positive cultures. There was no statistical difference between the groups in symptoms of dysuria, hematuria, frequency, flank pain, and nocturia (~ = .05). The physical parameters of age, blood pressure, pulse, and temperature were similar in the two groups (~ = .05), as were the types of infecting organisms (~ = .05). When comparing the two regimens, the ceftriaxone group cure rate (18 of 20, 90%) was not found to be significantly different from that of the TMS-treated control group (13 of 13) (~ = .05). [Rosenberg JM, Levy RC, Cicmanec JF, Hedges JR, Burke BM: Single-dose ceftriaxone treatment of urinary tract infections. Ann Emerg Med October 1985;14:970-972.] INTRODUCTION Patients with uncomplicated urinary tract infections (UTI)I often present to the ED. Single-dose antimicrobial therapy offers an attractive ahemative to the traditional five-to-ten-day antimicrobial course. Our study was undertaken to determine the efficacy of single-dose, intramuscular ceftriaxone compared to a five-day course of oral trimethoprim-sulfamethoxazole in women with uncomplicated UTI. Although other single-dose regimens have proven to be efficacious for this purpose, ceftriaxone has not been tested. Ceftriaxone, a new cephalosporin with prolonged biological half-life of eight hours and extended antibacterial coverage, has shown promise for the treatment of serious clinical infections.
Jack M Rosenberg, M D * Richard C Levy, MD* John F Cicmanec, PhDt Jerris R Hedges, MD* Barbara M Burket Cincinnati, Ohio From the Department of Emergency Medicine* and the Division of Urology,t University of Cincinnati Medical Center, Cincinnati, Ohio. Received for publication June 30, 1984. Revision received November 20, 1984. Accepted for publication March 27, 1985. Presented at the University Association for Emergency Medicine Annual Meeting in Louisville, Kentucky, May 1984. Address for reprints: Jack M Rosenberg, MD, Department of Emergency Medicine, University of Cincinnati Medical Center, 234 Goodman Street, Cincinnati, Ohio 45267.
METHODS Physicians working in the Center for Emergency Care at the University of Cincinnati were asked to enroll into the study female patients with initial laboratory and clinical symptoms suggestive of a urinary tract infection. Exclusion criteria included prior antibiotics; allergies to sulfa, trimethoprim, penicillins, or cephalosporins; pregnancy; medical complications (eg, diabetes); history of frequent UTI; urethral strictures; catheterizations or other recent instrumentation; and age less than 18. All patients enrolled in this study were treated according to a protocol approved by the University of Cincinnati Medical Center Committee on Human Research (institutional review board for human experimentation). Clinical evaluation involved careful history-taking with particular emphasis on presenting symptomatology and physical findings. The patients were asked to rate on an increasing integral scale of zero to four the degree of dysuria, flank pain, hematuria, nocturia, and frequency they experienced prior to ED presentation. Initial laboratory evaluation included urine analysis and midstream clean catch or straight catheterized culture and sensitivity. Symptomatic patients with a single-organism bacterial count of 10s or more
14:10 October 1985
Annals of Emergency Medicine
970/71
SINGLE-DOSE CEFTRIAXONE Rosenberg et al
TABLE. Results of other single-dose therapy trials
Anti biotic Amoxycillin Kanamycin Doxycycline Cephamandole Trimethoprim-sulfamethoxazole
Dosage 3 g 0.5 g 0.3 g 1 g 1.92 g
were said to have UTI. After written informed consent was obtained, the patients were entered into the study and randomized into two groups. One group received a single 500-mg i n t r a m u s c u l a r dose of ceftriaxone, reconstituted in 1% lidocaine to m i n i m i z e discomfort. The other group received a five-day oral regimen of trimethoprim 200 mg/sulfamethoxazole 800 mg (TMS) every 12 hours. Patients who received ceftriaxone were instructed to return for reexa m i n a t i o n after 24 hours and again five to nine days after treatment. A urine sample for culture and sensitivity was obtained at both follow-up visits. Patients who received TMS were asked to return after 48 to 72 hours, at the completion of therapy, and at five to nine days after therapy. As in the ceftriaxone group, urine cultures were obtained at each visit. Monetary incentive for enhancing compliance was provided; patients in both groups received $30 for c o m p l e t i o n of the study. P a t i e n t s were q u e s t i o n e d a b o u t symptoms and drug tolerance at both return visits. Cure was defined as relief of initial symptoms and a sterile urine throughout the follow-up period. Failure was defined as persistence or recurrence of the infection with the same organism by urine culture or the nonresolution of the presenting symptomatology. Statistical analysis of the discontinuous data between groups was performed using chi-square analysis with correction for continuity. Analysis of the continuous data was done using a two-tailed t test. Differences between groups were considered significant at the P = .05 level.
RESULTS Six hundred ninety-one unselected 72/971
Follow-up 1 week 1 week 1 week 1 week 8 to 12 days
No. Cures/Patients 27/35 16/37 37/45 37/53 12/15
female patients presented to the ED with clinical symptoms suggestive of a urinary tract infection during the study period. Fifty-two patients (8%) were entered into the study by physicians working in the Center for Emergency Care. Twenty percent of the pat i e n t s w e r e e x c l u d e d b e c a u s e of medical complications; 14% were currently on medications; 13% were allergic to the study drugs or closely related compounds; 10% were pregnant; 3% had complicated urinary tract infections; in 1% the ED residents were unaware of the study; and 3% were excluded due to other causes. Docum e n t a t i o n was not available to explain the exclusion of 28% of the patients. One patient was dropped from the study when it was subsequently determined that she had a history of recurrent UTI. The patients were randomized to either the TMS or ceftriaxone group. Of the 26 patients in the TMS group, five did not return for follow-up, and eight did not have significant bacteriuria on initial culture, leaving 13 subjects for full evaluation. In the ceftriaxone group two did not return for follow-up and four did not have significant bacteriuria. T h u s 20 patients were available for evaluation. There was no difference in compliance between the two groups. (X2 = 0.58) Escherichia coli was the infecting o r g a n i s m in 27 of the 52 p a t i e n t s (73%) who were enrolled in the study; staphylococcal species, in six (16%); Proteus, in two (5%); Klebsiella, in one (3%); and m i x e d flora, in one (3%). Growth of fewer than l0 s colonies was seen in 15 patients. N o significant difference in the organisms was seen between the two groups. There was no significant difference between the groups with regard to their degree of dysuria, frequency, hematuria, flank pain, or nocturia. The groups also were comparable in Annals of Emergency Medicine
Authors Bailey, Abbott (1976, 1977) Lubis et al (1979) Bailey (1980) Shaw et al (1980) Russ et al (1980)
m e a n p r e s e n t i n g age, t e m p e r a t u r e , blood pressure, and pulse. In the TMS group, all 13 of the compliant patients with a culture-positive UTI were cured by both clinical and bacteriologic criteria. In the ceftriaxone group, 18 patients were cured bacteriologically and clinically. One of the two p a t i e n t s w h o s e t r e a t m e n t failed had slowly abating symptoms and was placed on arnpicillin despite a sterile urine after 48 hours. The other ceftriaxone patient's urine was sterile 24 hours posttherapy, but she was reinfected at nine days by the same o r g a n i s m , w h i c h was r e s i s t a n t to ceftriaxone. This patient returned to thc urology clinic and was treated with ampicillin. Therefore 18 of 20 patients (90%) were cured by a single intramuscular injection of ceftriaxone. N o difference existed b e t w e e n the TMS and ceftriaxone cure rates. Typetwo error at the 60% difference level equaled 0.16. No complaints of adverse reactions were seen in the ceftriaxone group. In the TMS group one patient had a vaginal rash that resolved with discontinu a n c e of the m e d i c a t i o n . A n o t h e r woman left the study after developing gastrointestinal distress.
DISCUSSION Uncomplicated urinary tract infections are c o m m o n in the female population. Single-dose therapy has been advocated as a safe and effective alternative to a five- to 14-day antibiotic regimen. It offers the advantages of assured compliance, lower cost, and fewer side effects. 2 Our study suggests that single-dose ceftriaxone may be as effective as conventional therapy and offers the theoretical advantages of fewer side effects and greater compliance. T h i s l a t t e r b e n e f i t is especially i m p o r t a n t w h e n poor compliance is anticipated. Uncomplicated urinary tract infec14:10 October 1985
tions are t h o u g h t to be s u p e r f i c i a l bladder m u c o s a l i n f e c t i o n s t h a t are usually limited to the transitional epithelium, z Spontaneous cure is possible, b u t t h e u s e of a n t i b i o t i c s improves t h e c h a n c e of a f a v o r a b l e outcome. 1 Recent investigations have focused on the establishment of m i n i m u m effective doses for various antibiotic regimens. Several single-dose r e g i m e n s have been tried with differing success rates (Table).a The variable cure rate in t h e s e s t u d i e s , a s i d e f r o m t h e variability of t h e a n t i m i c r o b i a l agents, might be explained by the inclusion of upper UTI in some studies and the exclusion of resistant infections in other studies. Ceftriaxone,3, 4 a new third-generation cephalosporin w i t h an extended biological half-life, is active against a wide array of bacteria, including those likely to be encountered in an uncomplicated UTI. In our study, initial steri l i z a t i o n of t h e u r i n e was a c c o m plished in all patients, and all bacteria were initially sensitive to ceftriaxone. Our s t u d y was l i m i t e d to w o m e n with uncomplicated lower urinary tract infections who met specific clinical and laboratory criteria. T h e enrollment of patients into this study was a result of the efforts of residents assigned to our ED. To p e r m i t rigid comparison between treatment groups, upper urinary tract infections and infections of less than 10s bacteria per m i l l i l i t e r of urine were excluded from the study. The laboratory criteria of more than 10s bacteria per milliliter
14:10 October 1985
h a s b e e n s h o w n to m i s s a p p r o x i m a t e l y 3 3 % of t h e s y m p t o m a t i c w o m e n w h o actually have a UTI as established by suprapubic aspiration.S,6 Against a c o m m o n array of microorganisms,6 these antibiotic regimens demonstrated no significant difference in cure rate, although the study had a large type-two error. That is, there is considerable potential error in assuming that the two therapies are equivalent w h e n we were unable to detect a statistical difference. The inclusion of m o r e p a t i e n t s in a s i m i l a r s t u d y is n e e d e d to r e d u c e t h e p o t e n t i a l for such an error. In p a t i e n t s in w h o m s i n g l e - d o s e therapy failed, studies have indicated that such patients are candidates for a m o r e e x t e n s i v e w o r k - u p to e x c l u d e a n a t o m i c a l a b n o r m a l i t i e s . l Failure of single-dose therapy has not been reported to progress to acute pyelonephritis or bacteriemia, but no clinical series have studied this event. Does single-dose therapy of uncomplicated UTI cause an increase in recurrent infection rates? In our study one patient had recurrence of the initial infection by the d e v e l o p m e n t of resistance to ceftriaxone. Whether recurrent infections developed in other patients beyond the five- to nine-day f o l l o w - u p v i s i t is u n k n o w n , a n d should be studied.
CONCLUSION In the ED, the clinician treating unc o m p l i c a t e d u r i n a r y tract infections
Annals of Emergency Medicine
often starts therapy immediately w h i l e c u l t u r e s and s e n s i t i v i t i e s are pending. The experimental drug c e f t r i a x o n e in a single dose is suggested in our study to be a safe and efficacious therapy for uncomplicated UTI. As a study drug, no cost comp a r i s o n s c a n be m a d e . B e c a u s e of ceftriaxone's extended a n t i m i c r o b i a l coverage, long biological half-life, and limited n u m b e r of side effects, further research on this drug and the singledose regimen is warranted.
REFERENCES 1. Kunin CM: Detection, Prevention and Management of Urinary Tract Infections. Philadelphia, Lea and Febiger, 1979. 2. Bailey RR: Single Dose Therapy of Urinary Tract Infection. Boston, ADI8 Health Science Press, 1983. 3. Keenholtz SL, Jacobus NV, Tally FP, et al: In vitro activity of RO 13-9904 and GR 20263. Abstracts of 21st Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, Ilinois, 1981, No. 386. 4. Patel IH, Parsonnet M, Weinfeld R: Single p h a r m a k i n e t i c s and t o l e r a n c e of ceftriaxone following intramuscular administration in water or lidocaine. Abstracts of 21st Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, Illinois, 1981, No. 390. 5. Kormaroff AL: Acute dysuria in women. N EngI J Med 1984;310:369. 6. Stamm WE, Counts GW, Running KR, et al: Diagnosis of coliform infection in acutely dysuric women. N Engl J Med 1982;307:463-466.
972/73