Urinary Tract Infection Treatment Guidelines

What Is A Urinary Tract Infection

UTIs are common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract. The infections can affect several parts of the urinary tract, but the most common type is a bladder infection .

Kidney infection is another type of UTI. Theyre less common, but more serious than bladder infections.

Physical Examination And Diagnostic Testing

• References

The physical examination of patients with acute uncomplicated cystitis is typically normal, except in the 10 to 20 percent of women with suprapubic tenderness.10 Acute pyelonephritis should be suspected if the patient is ill-appearing and seems uncomfortable, particularly if she has concomitant fever, tachycardia, or costovertebral angle tenderness.

Further studies beyond urinalysis and urine cultures are rarely needed to diagnose acute uncomplicated cystitis. Patients who present with atypical symptoms of acute uncomplicated cystitis and those who do not respond to appropriate antimicrobial therapy may need imaging studies, such as computed tomography or ultrasonography, to rule out complications and other disorders.

Prevention Of Recurrent Uti

Recurrent UTI can be prevented by preventing constipation and avoidance of urine withholding behavior in toilet-trained children. Although increased oral fluid helps flush bacteria from the bladder, prompts frequent urination, and alleviates constipation, there is limited evidence that it is effective in preventing UTIs. In uncircumcised boys, gentle, daily retraction and cleaning should be performed in boys with phimosis, topical corticosteroid ointment or circumcision may be necessary to prevent UTI recurrence. There is no evidence in children to recommend cranberry juice for the prevention of UTIs. In a systematic review of studies in adults, researchers concluded that given the evidence, cranberry juice cannot currently be recommended for the prevention of UTIs.

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Diagnosis And Treatment Of Acute Uncomplicated Cystitis

RICHARD COLGAN, MD, and MOZELLA WILLIAMS, MD, University of Maryland School of Medicine, Baltimore, Maryland

Am Fam Physician. 2011 Oct 1 84:771-776.

Patient information: See related handout on treating a bladder infection , written by the authors of this article.

• References

Urinary tract infections are the most common bacterial infections in women. Most urinary tract infections are acute uncomplicated cystitis. Identifiers of acute uncomplicated cystitis are frequency and dysuria in an immunocompetent woman of childbearing age who has no comorbidities or urologic abnormalities. Physical examination is typically normal or positive for suprapubic tenderness. A urinalysis, but not urine culture, is recommended in making the diagnosis. Guidelines recommend three options for first-line treatment of acute uncomplicated cystitis: fosfomycin, nitrofurantoin, and trimethoprim/sulfamethoxazole . Beta-lactam antibiotics, amoxicillin/clavulanate, cefaclor, cefdinir, and cefpodoxime are not recommended for initial treatment because of concerns about resistance. Urine cultures are recommended in women with suspected pyelonephritis, women with symptoms that do not resolve or that recur within two to four weeks after completing treatment, and women who present with atypical symptoms.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

The combination of new-onset frequency and dysuria, with the absence of vaginal discharge, is diagnostic for a urinary tract infection.

Table 1 Symptoms/signs Of Uti Used For Classification

Cystitis18,21,22

Catheterized patients usually do not manifest symptoms of cystitis. Instead, monitor for symptoms of complicated UTI.16

No testing required if symptoms of UTI or systemic infection are absent6,16 If patient is symptomatic, collect urine for culture after removal of old catheter or from a newly inserted catheter.16

Catheters can be colonized with bacteria after 24 hours of insertion, and 100% are colonized within 1 month.5,16

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A Note On Preventative Techniques

There is currently no convincing evidence for adapting behavioural and personal hygiene measures to prevent recurrent UTIs in non-pregnant women.1

In pregnancy, a systematic review concluded that only hygiene measures were supported by evidence to be recommended in practice.6 Studies involving intake of cranberry juice, ascorbic acid, and a herbal product had limitations that cast doubt on their effectiveness further improved studies are needed.6 However, these substances appear to be safe to use in pregnancy.5

Aua Guidelines On Recurrent Uncomplicated Urinary Tract Infections In Women

The American Urological Association has issued its first guideline for the diagnosis and treatment of uncomplicated recurrent urinary tract infections , emphasizing the importance of cultures and antibiotic stewardship.

Evaluation

Women presenting with recurrent lower urinary tract infections should undergo a complete patient history and pelvic examination.

A diagnosis of rUTI must be based on documented positive urine culture results in association with prior symptomatic episodes.

An initial urine specimen that may be contaminated should prompt a repeat urine study collection of a catheterized specimen should be considered.

Index patients presenting with rUTI should not routinely undergo upper tract imaging and cystoscopy.

Before beginning treatment in patients with rUTI, urinalysis, urine culture, and sensitivity should be performed for each symptomatic acute cystitis episode.

Select patients with rUTI with acute episodes may be offered patient-initiated treatment while urine culture results are pending.

Asymptomatic bacteriuria

References

Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar. 52:e103-20. . .

Foxman B. The epidemiology of urinary tract infection. Nat Rev Urol. 2010 Dec. 7:653-60. .

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Pathogenesis Of Acute Pyelonephritis And Renal Scarring

The pathogenesis of acute pyelonephritis and renal scarring is complex and not fully understood. Most UTIs are ascending infections that start with periurethral colonization hematogenous spread occurs primarily in debilitated, obstructed, or immunocompromised patients, and these are mostly fungal and staphylococcal infections. The virulence of uropathogenic E coli is largely influenced by the presence of P fimbriae, also known as pyelonephritis-associated pili, and lipopolysaccharide. The binding of the P fimbriae to epithelial cells is mediated by the tip adhesin PapG. Bacterial lipopolysaccharide is important for the initiation of tissue inflammation. It is bound in the kidney by toll-like receptor 4, which is a transmembrane protein and a member of the toll-like receptor family. These receptors are present on the epithelial cells and parts of the renal tubule. Their activation leads to a release of proinflammatory cytokines and chemokines and the recruitment of neutrophils., Lipopolysaccharide also activates the recruited macrophages. The presence of macrophages, dendritic cells, and T cells in renal interstitium induces inflammation via modulation of immune response through recruitment and activation of neutrophils and the generation of reactive oxygen species, resulting in killing the pathogen.

Managing Lower Urinary Tract Infection

1.1.1 Be aware that lower urinary tract infection is an infection of the bladder usually caused by bacteria from the gastrointestinal tract entering the urethra and travelling up to the bladder.

1.1.2 Give advice about managing symptoms with self-care to all people with lower UTI.

Treatment for women with lower UTI who are not pregnant

1.1.3 Consider a back-up antibiotic prescription or an immediate antibiotic prescription for women with lower UTI who are not pregnant. Take account of:

• the severity of symptoms

• the risk of developing complications, which is higher in people with known or suspected structural or functional abnormality of the genitourinary tract or immunosuppression

• the evidence for back-up antibiotic prescriptions, which was only in non-pregnant women with lower UTI where immediate antibiotic treatment was not considered necessary

• previous urine culture and susceptibility results

• previous antibiotic use, which may have led to resistant bacteria

• preferences of the woman for antibiotic use.

1.1.4 If a urine sample has been sent for culture and susceptibility testing and an antibiotic prescription has been given:

• review the choice of antibiotic when microbiological results are available, and

• change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not already improving, using a narrow-spectrum antibiotic wherever possible.

Treatment for pregnant women and men with lower UTI

1.1.7 For pregnant women with lower UTI:

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International Clinical Practice Guidelines

• References

In 2010, a panel of international experts updated the 1999 Infectious Diseases Society of America guidelines on the treatment of acute uncomplicated cystitis and pyelonephritis in women. The panel reviewed the literature, including the Cochrane Database of Systematic Reviews, and provided an evidence-based guideline for women with uncomplicated bacterial cystitis and pyelonephritis.16,17 The IDSA collaborated with the European Society of Clinical Microbiology and Infectious Diseases, and invited representation from diverse geographic areas and a wide variety of specialties, including urology, obstetrics and gynecology, emergency medicine, family medicine, internal medicine, and infectious diseases. Levels-of-evidence ratings were assigned to recommendations on the use of antimicrobials for the treatment of uncomplicated UTIs.

Urinary Tract Infection: Clinical Practice Guideline For The Diagnosis And Management Of The Initial Uti In Febrile Infants And Children 2 To 24 Months

Kenneth B. Roberts, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics September 2011 128 : 595610. 10.1542/peds.2011-1330

To revise the American Academy of Pediatrics practice parameter regarding the diagnosis and management of initial urinary tract infections in febrile infants and young children.

Analysis of the medical literature published since the last version of the guideline was supplemented by analysis of data provided by authors of recent publications. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed and graded.

Changes in this revision include criteria for the diagnosis of UTI and recommendations for imaging.

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Common Errors In The Diagnosis Of Uti

Differentiation of APN from cystitis can be difficult particularly in preverbal children, and in the febrile infant, the distinction might be considered largely academic because treatment will be similar. Because most cases of APN are due to ascending infection, many patients have both upper- and lower-tract symptoms, further blurring the distinction between cystitis and APN. However, an effort should be made to localize the infection and to identify the causative organism . Furthermore, unlike APN that needs second- or third-generation cephalosporin for at least 1 week, uncomplicated bacterial cystitis generally responds well to the short duration of first-generation cephalosporin, trimethoprim-sulfamethoxazole, or nitrofurantoin. The utility of currently available screening tests is limited. The evidence suggests that an increased serum C-reactive protein or procalcitonin level is suggestive of APN. The erythrocyte sedimentation rate does not appear useful in diagnosing APN. Some other features that may be helpful in differentiating cystitis from APN are shown in .

The Process Of Treatment Guideline Development

The committee determined the method of treatment guideline development. The basic objective was to update the Korean guideline developed in 2011. For the existing key questions from the guideline, study findings that were published after the guideline was developed in 2011 were searched and added to the guideline, and the level of recommendation was determined. In addition, important questions that required additional findings were answered using the adaptation method. For questions regarding uncomplicated cystitis, the adaptation method was used. For the remaining four diseases, key questions were summarized and partially revised in the guideline.

1) Guideline search

Guidelines for the five diseases that were developed after 2011 were searched in the National Guideline Clearinghouse and OVID MEDLINE. They were searched using disease names on the NGC, and using Mesh terms related to the diseases and guideline search filters on MEDLINE . Search results are shown in . Two committee members selected seven guidelines for the five diseases from the search results.

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Know How To Manage Suspected Pyelonephritis

In adults aged 16 years and over with suspected pyelonephritis:4

• admit people to hospital who have symptoms or signs suggesting a more serious illness or condition, such as sepsis
• consider referring or seeking specialist advice for people with acute pyelonephritis if they:
• are significantly dehydrated or unable to tolerate oral fluids and medicines or
• are pregnant or
• have a higher risk of developing complications .

Tables 1 and 2 show suggested regimens for oral antimicrobial therapy in uncomplicated acute pyelonephritis.4

Table 1: Antibiotics for non-pregnant women and men aged 16 years and over with acute pyelonephritis4

Antibiotic

American Urological Association Canadian Urological Association And Society Of Urodynamics Female Pelvic Medicine & Urogenital Reconstruction

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

Clinical guidelines on urinary tract infection in women were released in May 2019 by the American Urological Association , Canadian Urological Association , and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction .

The American Urological Association has issued its first guideline for the diagnosis and treatment of uncomplicated recurrent urinary tract infections , emphasizing the importance of cultures and antibiotic stewardship.

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Forming A Treatment Guideline Committee

The development committee consisted of a chairman and five committee members recommended by the Korean Society for Chemotherapy and the Korean Society of Infectious Diseases, one committee member recommended by the Korean Association of Urogenital Tract Infection and Inflammation, two committee members recommended by the Korean Urological Association, and two committee members recommended by the Korean Society of Nephrology.

Indications For Specialist Referral

Most patients with recurrent uncomplicated UTI may be treated successfully by family physicians. Specialist referral for recurrent uncomplicated UTI is indicated when risk factors for complicated UTI are present . Referral is also indicated when a surgically correctable cause of UTI is suspected or the diagnosis of UTI as a cause for recurrent lower urinary tract symptoms is uncertain. Prior to referral, culture of the urine while symptomatic and 2 weeks after sensitivity-adjusted treatment may aid in confirming the diagnosis of UTI, as well as guiding further specialist evaluation and management.

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Know About Possible Options For Preventing Recurrent Uti

NICE Guideline 112 comments that some non-pregnant women may wish to try D-mannose as self-care treatment, or cranberry products, though the evidence for benefit of these is uncertain.5 People taking either product should be advised about the sugar content.5 Should this not help, consider vaginal oestrogens in post-menopausal women .5 Should UTIs still recur, consider single-dose antibiotics when the patient is exposed to the known trigger.5 Finally, consider daily prophylactic antibiotics. For full details, including recommendations about when to refer and when to seek specialist advice, see NG112 on Urinary tract infection : antimicrobial prescribing and the helpful 2-page visual summary.5

How To Feel Better

If your healthcare professional prescribes you antibiotics:

• Take antibiotics exactly as your healthcare professional tells you.
• Do not share your antibiotics with others.
• Do not save antibiotics for later. Talk to your healthcare professional about safely discarding leftover antibiotics.

Drink plenty of water or other fluids. Your healthcare professional might also recommend medicine to help lessen the pain or discomfort. Talk with your healthcare professional if you have any questions about your antibiotics.

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Urinary Tract Infection : Antimicrobial Prescribing

NICE guideline

This guideline sets out an antimicrobial prescribing strategy for lower urinary tract infection in children, young people and adults who do not have a catheter. It aims to optimise antibiotic use and reduce antibiotic resistance.

See a 3-page visual summary of the recommendations, including a table to support prescribing decisions.

• People with lower urinary tract infection, their families and carers

Urinary Tract Infection Treatment Guidelines

Urinary tract infection is the presence of micro-organisms in the urine or tissues of the normally sterile genitourinary tract.

Infection may be localized to the bladder alone or the kidneys or, in men the prostate.

Acute uncomplicated UTI occurs in women with a normal genitourinary tract and usually manifests as acute cystitis .

Complicated UTI occurs in individuals with structural or functional abnormalities of the genitourinary tract, including those with indwelling devices such as urethral catheters.

Congenital abnormalities of the genito-urinary tract predispose children to UTI. Proven UTI in a child or recurrent UTI requires further urogenital evaluation.

Definitive treatment of UTI depends on culture and sensitivity reports. However, empirical treatment may be initiated while awaiting the report.

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Remember The Symptoms And Signs Of Utis And Pyelonephritis

Symptoms of a lower UTI in adults can include urinary frequency/urgency, dysuria, new-onset nocturia, turbid urine, haematuria, and suprapubic tenderness.3

Pyelonephritis can present with fever , chills, flank pain, nausea, vomiting, or renal angle tenderness, with or without the typical symptoms that present with a lower urinary tract infection.1

As well as these specific urinary tract symptoms, elderly people can present with increased debility, worsening cognition, and recent-onset incontinence.3

Know The Red Flags For Possible Cancer

Refer people using a suspected cancer pathway referral for bladder cancer if they are:7

• aged 45 and over and have:
• unexplained visible haematuria without UTI or
• visible haematuria that persists or recurs after successful treatment of UTI, or

aged 60 and over and have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test.

Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained UTI.7

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Patients For Whom The Guideline Is Applicable

This guideline is on the use of antibiotics for community-acquired UTIs affecting patients aged 18 years or older. The guideline targets asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, complicated pyelonephritis related to urinary tract obstruction, and acute bacterial prostatitis. Hospital-acquired infections that occurred 48 hours after hospital admission or catheter-associated UTIs were excluded. Patients with UTIs who were diabetic, were immunosuppressed, or had other underlying chronic illnesses, and were thus associated with complex factors aside from urinary tract obstruction, were also excluded from the target patient group of this guideline.