Iranian Journal of Clinical Infectious Diseases

2010;5(2):70-74 ORIGINAL ARTICLE

©2010 IDTMRC, Infectious Diseases and Tropical Medicine Research Center

Comparison of 3-day and 7-day ciprofloxacin regimen for the

treatment of uncomplicated urinary tract infection in women:
A randomized double-blind clinical trial
Bahman Haghighi1, Hyaide Oskuilar2, Omid Nejadi3, Noushin Etesam4, Hamid Mostafavi4,
Reza Alaghehbandan5, Abdolaziz Rastegar Lari3*
1
Nyayesh Clinic, Shahriar, Tehran, Iran
2
Imam Sajad Hospital, Shahriar, Tehran, Iran
3
Antimicrobial Resistance Research Center, Department of Microbiology, Iran University of Medical Sciences, Iran
4
Exir Pharmaceutical Company, Tehran, Iran
5
Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL, Canada

ABSTRACT
Background: Urinary tract infections (UTIs) are among the most commonly bacterial infections in clinical practice.
Almost half of all women experience at least one urinary tract infection in their lifetime. This study compared efficacy
and safety of 3-day and 7-day ciprofloxacin regimen for the treatment of uncomplicated urinary tract infection in
women.
Patients and methods: A total of 76 patients were randomly assigned to two treatment groups. One group received
ciprofloxacin, 250 mg twice a day for 3 days (n=39) and the other group received ciprofloxacin 250 mg twice a day for 7
days (n=37). Subjects were visited and assessed three times during the study period (baseline, end of treatment, and test
for cure). Clinical and bacteriological responses to the treatment were compared between the two groups.
Results: There was no significant difference between the two groups in terms of age distribution and clinical
signs/symptoms during the baseline visit. There was no significant difference between clinical or bacteriological
responses between the two groups. Three-day regimen of ciprofloxacin showed high microbiological eradication rate for
E. coli (66.7%) which was similar to the eradication rate observed for 7-day regimen (64.8%). No statistically significant
difference was found in adverse effects between the groups, except for nausea (p=0.041).
Conclusion: A 3-day ciprofloxacin regimen appeared to be safe and effective for the treatment of UTI in women.
Therefore, shorter therapy duration with ciprofloxacin can potentially improve patient compliance and decrease costs.

Keywords: Urinary tract infections, Ciprofloxacin, Women.

(Iranian Journal of Clinical Infectious Diseases 2010;5(2):70-74).

INTRODUCTION
1
Urinary tract infections (UTIs) cause over 7 and one million emergency visits per year in the
million physician office visits (mostly for cystitis) United States (1,2). Trimethoprim-
sulfomethoxazole (TMP-SMX) is currently the
Received: 17 October 2009 Accepted: 25 April 2010 first-line treatment for uncomplicated UTIs. Given
Reprint or Correspondence: Abdolaziz Rastegar Lari, PhD.
Antimicrobial Resistance Research Center, Department of increasing bacterial resistance to TMP-SMX (3,4),
Microbiology, Iran University of Medical Sciences, Iran. fluoroquinolones are now recommended as first-
E-mail: [email protected]

Iranian Journal of Clinical Infectious Disease 2010;5(2):70-74

 Haghighi B. et al 71

line treatment in areas with high bacterial single uropathogen), they were excluded from the
resistance. Ciprofloxacin is a fluoroquinolone study. Meanwhile, the following exclusion criteria
antimicrobial agent with a broad spectrum activity were applied at baseline: three or more UTIs in
against gram-negative and gram-positive bacteria. previous year, signs or symptoms of vaginal
It is an effective treatment for a wide variety of infections, overt pyelonephritis, structural
bacterial infections, including UTIs. However, abnormalities, an indwelling catheter, renal
gastrointestinal side effects such as nausea and insufficiency, gastrointestinal disorder, and
diarrhea are the most common causes of gynecologic disorder (8) as well as receiving
discontinuation of ciprofloxacin therapy (5,6). medications containing products such as antacids,
This study compared the efficacy and safety of sucralfate, calcium, iron or zinc supplements and/or
a 3-day ciprofloxacin and 7-day ciprofloxacin for any antimicrobial treatments within two days prior
the treatment of uncomplicated urinary tract to the study.
infection in women. Treatment procedure: A total of 76 patients
were randomly assigned to two groups; one group
received ciprofloxacin (Exir Pharmaceutical Co.),
PATIENTS and METHODS 250mg twice a day for 3 days (n=39), and the other
Study design: This study is a randomized group received ciprofloxacin 250mg twice a day
double-blind clinical trial, comparing 3-day and 7- for 7 days (n=37). Each subject was visited thrice
day ciprofloxacin regimen for the treatment of by a clinician at baseline (visit 1), end of the
uncomplicated UTI in women. Study subjects were treatment (visit 2), and 4 weeks following the
randomly selected from female patients with therapy (visit 3). At the baseline, demographic, and
clinical evidence of acute uncomplicated UTIs. All medical and drug history of patients was gathered.
subjects were requested to complete an informed Meanwhile, a thorough physical examination and
consent prior to study. Eligible patients were assessment of clinical signs and symptoms of UTIs
randomly assigned, in a double blind, double- were performed. Further, a urine sample for pyuria
dummy manner to either ciprofloxacin 250 mg evaluation, culture and susceptibility testing was
twice a day for 3 days, or ciprofloxacin 250 mg obtained. During the second visit (3rd and 7th day
twice a day for 7 days in a ratio of 1:1. for respective groups), clinical information
Eligibility and accrual: The following inclusion concerning the progression or regression of UTIs
criteria were applied at baseline: non-pregnant signs/symptoms along with a urine sample for
female adult (≥18 years old) with clinical evidence culture were obtained. At the third visit, response
of acute uncomplicated UTIs (dysuria, urgency, to the therapy was assessed.
frequency of urination and/or suprapubic pain), and Bacterial assessment and outcome measures:
onset of symptoms less than 72 hours prior to Antimicrobial efficacy was evaluated by
study. Patients must have a positive pretreatment conventional clinical and laboratory determinants,
clean-catheter midstream urine culture defined as including serial urine culture obtained by the
≥105 CFU/ml of an identified single uropathogen midstream 'clean-cath' technique at the baseline
(7). It should be noted that all patients, who visit (within 48 hours before the first dose of study
initially entered the study and had clinical drug) and the test for cure visit (one month after
presentations of UTI, were tested for urine culture treatment). The uropathogens were identified by
and subsequently treated with ciprofloxacin. If the standard microbiologic techniques and tested for
urine culture results did not meet the above- susceptibility to ciprofloxacin using Disk Diffusion
mentioned criteria (≥105 CFU/ml of an identified Susceptibility Testing (Kirby-Bauer Method)

Iranian Journal of Clinical Infectious Disease 2010;5(2):70-74

72 Comparing two regimens of ciprofloxacin for UTI

recommended by the National Committee on suprapubic pain (51%), followed by nausea (22%),
Clinical Laboratory Services (NCCLS). fever (16%) and genital tenderness (4%). Figure 1
In this study bacteriologic response at the end of shows prevalence of different uropathogens. The
treatment (visit 2) was considered as the primary most frequent uropathogen was E. coli in both
bacteriological efficacy variable. The bacteriologic therapy groups (69% in 3-day and 73% in 7-day
response was classified as eradication and regimen). In this study, antimicrobial susceptibility
persistence. Eradication was defined as a reduction of uropathogens to ciprofloxacin in 3-day and 7-
of uropathogen colony count from ≥105 CFU/ml at day treatment groups were 94.9% (37 of 39) and
study entry to <104 CFU/ml, only at the second 75.7% (28 of 37), respectively (NS).
visit. Persistence was defined as growth of the
original uropathogen to ≥104 CFU/ml from a urine 80
70
sample taken after therapy completion. These 60
50
definitions are consistent with prior similar 40
30
published studies (9,10). 20 3-day regime
Clinical assessment: Clinical response was 10 7-day regime
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clinical UTIs signs and symptoms (dysuria,
urgency, frequency of urination and/or suprapubic Figure 1. Distribution of pathogens identified in
urine sample of patients with UTIs
pain) and patient's primary complaint.
Clinical response was classified as Overall bacteriological eradication rate for 3-
improvement, relative improvement and failure. day and 7-day regimen was 74.4% and 64.9%,
Improvement was defined as complete relief of all respectively (p=0.108). Figure 2 shows
clinical UTIs signs and symptoms. Relative bacteriological response in both groups according
improvement was defined as regression of clinical to the uropathogens found in urine. The 3-day
UTIs signs and symptoms. Failure was defined as regimen showed high microbiological eradication
persistence or progression of any clinical UTIs rate for E. coli (66.7%) which was similar to the
signs or symptoms or appearance of new signs or eradication rate observed for 7-day regimen
symptoms. It should be noted that these definitions (64.8%).
are consistent with prior similar published studies In our setting, clinical failure rate was 25.6%
(9,10). (10 of 39) and 29.7% (11 of 37), respectively (NS).
Safety assessment: All study subjects who Figure 3 demonstrates clinical response in both
received at least two doses (1 day) of ciprofloxacin
were included in the safety analysis. Medication 20
18
related adverse effects were obtained by a 16
14
12
physician during the final visit. 10
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2 7-day regime
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group were excluded due to drop out and failure to

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follow up. The most frequent signs and symptoms Figure 2. Bacteriological response in both treatment
were frequency (84%), dysuria (59%) and groups at second visit

Iranian Journal of Clinical Infectious Disease 2010;5(2):70-74

 Haghighi B. et al 73

groups according to patients’ signs and symptoms compare efficacy and safety of a 3-day with a 7-
during the third visit. day ciprofloxacin regimen for the treatment of UTI.
Distribution of meditation related adverse In this study, there were no significant
effects is presented in figure 4. No statistically differences in clinical or bacteriological responses
significant difference was found between the two between the two studied groups. In a large,
groups, except for nausea (p=0.041). multicenter, double-blind clinical trial, Stein and
Philip (9,11) found that a 3-day treatment regimen
30 using a single daily 400mg dose of temafloxacin to
25
20
be as effective as a 7-day course of ciprofloxacin in
15 women with acute uncomplicated UTI.
10
5
3-day regime Our study showed that microbiological
7-day regime
0 eradication rate of E. coli was more or less similar
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in 3-day and 7-day regimen of ciprofloxacin

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(66.7% vs. 64.8%). While the resistance of E. coli

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and other gram negative pathogens to TMP-SMX

Figure 3. Clinical response in both treatment groups and ampicillin has risen markedly over the past
at the third visit
decade, ciprofloxacin has maintained high activity
against these organisms (9). Additionally, adverse
30
drug effects such as nausea was significantly lower
25
20 when the 3-day and 7-day regimens were compared
15 (p=0.041). In a randomized, double-blind study of
10
5
3-day regime 891 women with uncomplicated UTI, Henry et al.
7-day regime
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immediate-release ciprofloxacin 250mg twice

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daily, each administered orally for 3 days. The

Figure 4. Frequency of adverse drug side effects in
both groups authors reported that the incidence of treatment-
related adverse events was 10.4% in women who
received extended-release ciprofloxacin and 9.2%
among those treated with the immediate-release
DISCUSSION formulation (10).
Ciprofloxacin was produced by Iranian Naber et al., in a double-blind, randomized
pharmaceutical companies and introduced to the study in adult female patients who received either
market in 1990s. Considering the high rate of gatifloxacin (400mg as a single shot or 3 days of
TMP-SMX resistance for the treatment of UTIs, 200mg once daily) or ciprofloxacin (250mg given
clinicians in Iran commenced prescribing twice daily for 3 days), reported that administration
ciprofloxacin as an alternative choice for the of gatifloxacin 200mg once daily for 3 days, and
treatment of UTIs. Along with other antibiotics, gatifloxacin 400mg as a single shot is equivalent to
ciprofloxacin also became resistant to various ciprofloxacin 250mg twice daily for 3 days for the
microorganisms including urinary tract infections treatment of acute uncomplicated lower UTIs.
pathogens. Factors such as overuse and/or They also found that all treatment groups showed a
inappropriate use of ciprofloxacin in Iran prompted similar safety profile and that the incidence of
the authors to conduct this study to investigate and treatment-related adverse events was comparable,

Iranian Journal of Clinical Infectious Disease 2010;5(2):70-74

74 Comparing two regimens of ciprofloxacin for UTI

the majority of adverse events were of mild or 5. Blondeau JM. Current issues in the management of
moderate intensity and the medications were well urinary tract infections: extended-release ciprofloxacin
as a novel treatment option. Drugs. 2004;64(6):611-28.
tolerated. In our study no serious treatment-related
6. Davis R, Markham A, Balfour JA. Ciprofloxacin. An
adverse events occurred in either group and only updated review of its pharmacology, therapeutic efficacy
two women in each group stopped treatment and tolerability. Drugs. 1996;51(6):1019-74.
because of adverse events. The overall incidence 7. Fourcroy JL, Berner B, Chiang YK, Cramer M, Rowe
was low, and the most common adverse events L, Shore N. Efficacy and safety of a novel once-daily
were nausea and headache. extended-release ciprofloxacin tablet formulation for
treatment of uncomplicated urinary tract infection in
This study provides further evidence that a 3- women. Antimicrob Agents Chemother.
day ciprofloxacin is an effective treatment for 2005;49(10):4137-43.
patients with UTIs. Furthermore, the patient’s 8. Richard GA, Mathew CP, Kirstein JM, Orchard D,
compliance for a 3-day ciprofloxacin is better. Yang JY. Single-dose fluoroquinolone therapy of acute
Hence, this may reduce the emerging and uncomplicated urinary tract infection in women: results
from a randomized, double-blind, multicenter trial
increasing antimicrobial resistance which is highly comparing single-dose to 3-day fluoroquinolone
associated with over use of antibiotics in Iran. regimens. Urology. 2002;59(3):334-9.
In summary, the results of this study 9. Stein GE, Philip E. Comparison of three-day
demonstrated that a 3-day ciprofloxacin regimen temafloxacin with seven-day ciprofloxacin treatment of
urinary tract infections in women. J Fam Pract.
for the treatment of UTI appeared to be safe and
1992;34(2):180-4.
effective. Our findings may suggest that shorter
10. Henry DC Jr, Bettis RB, Riffer E, Haverstock DC,
therapy duration of ciprofloxacin regimen can Kowalsky SF, Manning K, et al. Comparison of once-
potentially result in improved patient compliance daily extended-release ciprofloxacin and conventional
and decreased costs. twice-daily ciprofloxacin for the treatment of
uncomplicated urinary tract infection in women. Clin
Ther. 2002;24(12):2088-104.
ACKNOWLEDGEMENT 11. Naber KG, Allin DM, Clarysse L, Haworth DA,
James IG, Raini C, et al. Gatifloxacin 400 mg as a single
This study was conducted at Iran University of shot or 200 mg once daily for 3 days is as effective as
Medical Sciences. We would like to thank our staff ciprofloxacin 250 mg twice daily for the treatment of
for their kind cooperation. patients with uncomplicated urinary tract infections. Int
J Antimicrob Agents. 2004;23(6):596-605.

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Iranian Journal of Clinical Infectious Disease 2010;5(2):70-74