Population: Adults with urinary tract infection.
Organizations
ACOG 2008, EAU 2023, IDSA 2011, NICE 2018, AUA 2019
Recommendations
Evaluation
–Perform a urinalysis or dipstick testing for symptoms of a UTI: dysuria, urinary frequency, suprapubic pain, or hematuria.
–Send urine culture in men, pregnant women, children, those with a history of resistant bacteria, suspect pyelonephritis, symptoms do not resolve, or atypical symptoms.
Management
–Use acetaminophen rather than NSAIDs for pain control.
–No evidence for cranberry products or urine alkalization for treatment.
–Duration of antibiotics (consider any previous culture results and sensitivities):
• Uncomplicated cystitis: 3–7 d (nitrofurantoin requires 5–7 d).
• Uncomplicated pyelonephritis: 7–10 d.
• Complicated pyelonephritis or UTI: 3–5 d after control/elimination of complicating factors and defervescence.
–Empiric antibiotics for uncomplicated cystitis1:
• TMP-SMX 800 mg/160 mg BID × 3 d (not recommended if local resistance rate >20%).
• Nitrofurantoin monohydrate 100 mg BID × 5 d.
• Fosfomycin 3 g PO × 1 (second line).
• Beta-lactam antibiotics are alternative agents.2
–Empiric antibiotics for complicated UTI or uncomplicated pyelonephritis:
• Ceftriaxone or cefuroxime.
• Aminoglycosides.
–Fluoroquinolones: only use if there are not alternative antimicrobials.
–Empiric antibiotics for complicated pyelonephritis:
• Fluoroquinolones: only use if there are not alternative antimicrobials.
• Piperacillin-tazobactam.
• Carbapenem.
• Aminoglycosides.
–Consider a fluoroquinolone for symptoms of pyelonephritis or for refractory UTI, but only use if there are not alternative antimicrobials.
–Special circumstances (NICE 2018):
• Pregnant women: cephalexin 500 mg BID or TID × 7–10 d.
• Men: nitrofurantoin, TMP-SMX, ciprofloxacin, or levofloxacin.
Practice Pearls
• EAU recommends 7 d of antibiotics for men with otherwise uncomplicated cystitis.
• EAU suggests the following options for antimicrobial prophylaxis of recurrent uncomplicated UTIs in nonpregnant women:
- Nitrofurantoin 50 mg PO daily.
- TMP-SMX 40/200 mg daily.
• EAU suggests the following options for antimicrobial prophylaxis of recurrent uncomplicated UTIs in pregnant women:
- Cephalexin 125 mg PO daily.
• Once urine culture and sensitivity results are known, antibiotics can be adjusted to the narrowest spectrum antibiotic.
Sources
–http://www.guidelines.gov/content.aspx?id=12628
–http://www.uroweb.org/gls/pdf/Urological%20Infections%202010.pdf
–http://www.guidelines.gov/content.aspx?id=25652
–http://guidelines.gov/content.aspx?id=12628
–http://cid.oxfordjournals.org/content/52/5/e103.full.pdf+html
–http://nice.org.uk/guidance/ng111
–http://nice.org.uk/guidance/ng109
–https://www.auanet.org/guidelines/recurrent-uti
Population: Febrile children 2–24 mo with suspected UTI.
Organizations
AAP 2016, NICE 2022, AAP 2021
Recommendations
–Diagnose a UTI if patient has pyuria, abnormal urinalysis, and ≥50,000 colonies/mL single uropathogenic organism.
–Obtain midstream sample for urine dipstick and culture prior to antibiotics. Bagged specimens can be used for urinalysis, but not for culture. Collect catheterized specimen or suprapubic aspiration for culture only if urinalysis suggests infection.
–Obtain blood cultures if toxic appearing.
–Obtain a renal and bladder ultrasound in all infants 2–24 mo with a febrile UTI.
–Treat febrile UTIs with 7–14 d of antibiotics and tailor antibiotics to culture result.
–Assume upper UTI with bacteriuria and fever (and flank pain).
–Antibiotic prophylaxis is not indicated for a history of febrile UTI.
–A voiding cystourethrogram (VCUG) is indicated if ultrasound reveals hydronephrosis, renal scarring, or other findings of high-grade vesicoureteral reflux, and for recurrent febrile UTIs.
Practice Pearls
• Urine obtained through catheterization has a 95% sensitivity and 99% specificity for UTI.
• Bag urine cultures have a specificity of approximately 63% with an unacceptably high false-positive rate. Only useful if the cultures are negative.
• Increased rate of false-positives if the renal ultrasound is performed during acute phase of illness. Consider delaying until illness has defervesced.
• Refer babies <3 mo with suspected UTI to pediatric speciality care.
Sources
–https://pubmed.ncbi.nlm.nih.gov/34281996/
–http://pediatrics.aappublications.org/content/early/2016/11/24/peds.2016-3026
–www.nice.org.uk/guidance/ng224
Population: Adults with pyelonephritis.
Organizations
ACP 2021, ACR 2022
Recommendations
Evaluation
–Diagnosis: urinary symptoms plus fever and costovertebral tenderness.
–Obtain urine culture prior to the initiation of antibiotics.
–Complicated pyelonephritis: obstruction, male sex, immunosuppression, stone disease, anatomic or functional urinary tract abnormality.
–Imaging (ACR):
• No imaging needed for suspect pyelonephritis, first-time presentation and uncomplicated history (ie, no history of pyelonephritis, diabetes, immunocompromise, stones or obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy).
• CT abdomen and pelvis with IV contrast is usually appropriate if suspected acute pyelonephritis but complicated (see above).
• CT abdomen and pelvis with IV contrast (or with and without IV contrast) is usually appropriate if there is a history of renal stones or renal obstruction or with a history of pelvic renal transplant with native kidneys in situ and no other complication (see above).
Management
–Hospitalize patients with severe illness, elevated creatinine, severe pain, or who cannot tolerate oral intake.
–Obtain imaging, either ultrasound or CT scan, in patients with severe illness, new renal failure, history of stones, ureteral colic, concern for obstruction (ie, BPH), high urine pH >7, or failure to respond to therapy.
–Men and women with uncomplicated pyelonephritis: prescribe fluoroquinolone × 5–7 d or TMP-SMX × 14 d.
–Ciprofloxacin 500 mg PO BID × 5 d, or 1000 mg PO daily × 5–7 d or levofloxacin 750 mg PO × 5–7 d.
–Ceftriaxone 1 g IV once with transition to oral therapy for patients who cannot take oral therapy initially.
–Second line:
• TMP-SMX 160/800 mg PO BID × 14 d.
• Cefixime 400 mg PO daily.
• Amoxicillin-clavulanate 875/125 mg PO BID.
–If high risk for resistance, may need inpatient parenteral therapy.
Sources
–Lee, R. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Ann Intern Med. 2021;174(6):822-827.
–American College of Radiology Appropriateness Criteria: Acute Pyelonephritis. 2022. https://acsearch.acr.org/docs/69489/Narrative/
Population: Adult women with recurrent UTI.
Organizations
AUA 2022, EAU 2022
Recommendations
Evaluation
–Perform complete history and perform pelvic exam.
–Obtain results of previous cultures and microbial sensitivity.
–Ensure clean, noncontaminated sample with consideration for catheterized specimen.
–Avoid routine imaging and cystoscopy.
Management
–Do not treat asymptomatic bacteriuria and omit surveillance screening.
–Provide patient-initiated treatment while awaiting culture.
–Recommend cranberry prophylaxis.
–Use first-line therapy (ie, nitrofurantoin, TMP-SMX, fosfomycin) and tailor based on local antibiogram.
–Reserve fluoroquinolones only when culture data support the use and there are not alternative antimicrobials.
–Use short duration of therapy (≤7 d).
–Repeat culture if UTI only if symptoms persist following antimicrobial therapy. Do not perform test of cure if symptoms resolve.
–Prescribe vaginal estrogen in peri- and postmenopausal women.
–Prescribe antimicrobial prophylactic antibiotics with caution.
–Use antimicrobial prophylaxis when non-antimicrobial interventions have failed.
Sources
–https://www.auanet.org/guidelines-and-quality/guidelines/recurrent-uti