Background: Urinary tract infections (UTIs) are common in young children and women and even more so in pregnant women. Ciprofloxacin has been a long-used regime to treat UTIs, although recently the paradigm has shifted towards Fosfomycin. This shift is driven by rising antibiotic resistance, safety concerns with fluoroquinolones, and the need for alternative treatments with broader efficacy and fewer adverse effects. This systematic review and meta-analysis assess the effectiveness and safety of Fosfomycin compared to Ciprofloxacin for treating urinary tract infections in adults.
Methods: A systematic search was conducted across PubMed, EMBASE, Cochrane Library, Web of Science, Google Scholar, and Scopus using search strings combining "Fosfomycin," "Ciprofloxacin," and "urinary tract infections." Study selection and screening were managed using Covidence, with duplicates removed. Four randomized controlled trials met the inclusion criteria following primary and secondary screening. Data analysis was performed using Review Manager (RevMan), with results presented as forest plots. A random-effects model was applied in cases of significant heterogeneity. The outcomes assessed included clinical remission, bacterial eradication, and adverse effects, based on data from three of the included studies.
Results: Four studies matched our inclusion criteria and were processed further for analysis. For bacterial eradication, the total number of patients was 334 patients, bacterial eradication during 10 days was achieved in 143 participants in the fosfomycin group and 110 participants in the ciprofloxacin group. Bacterial eradication was significantly higher in the fosfomycin group compared to the ciprofloxacin group (OR 2.03, 95% CI 1.22-3.36, p = 0.006). For clinical remission, no significant difference was found in 3 studies in a total of 278 patients (OR 1.26, 95% CI 0.72-2.21, p = 0.42). Out of a total of 356 patients, 74 experienced adverse effects in the fosfomycin group and 46 in the ciprofloxacin group. The appearance of adverse effects was significantly higher in the fosfomycin group (OR 2.66, CI 1.53-4.62, p = 0.0005).
Conclusion: The results of our meta-analysis show that bacterial eradication was significantly higher in the Fosfomycin group compared to the Ciprofloxacin group. There was no difference between the two drugs in terms of clinical remission. The appearance of adverse effects was significantly higher in the Fosfomycin group. Despite a higher incidence of adverse effects, Fosfomycin demonstrated superior bacterial eradication, suggesting its potential role as an effective empirical option, particularly in regions with elevated fluoroquinolone resistance. Hence, it was deduced that Fosfomycin is more effective than Ciprofloxacin for bacterial eradication in the treatment of urinary tract infections. These findings are influenced by significant heterogeneity in study design, populations, and outcome definitions, which should be considered when interpreting the pooled estimates.
Keywords: Anti-bacterial agents; Ciprofloxacin; Drug resistance; Fosfomycin; Urinary tract infections.
© 2025. The Author(s), under exclusive licence to Springer Nature B.V.