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"Guidelines for Antimicrobial Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women"

current
Published: Clinical Infectious Diseases ; 2011 ; 52 : e103 -e120

Abstract

A Panel of International Experts was convened by the Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) to update the 1999 Uncomplicated Urinary Tract Infection Guidelines by the IDSA. Co-sponsoring organizations include the American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases–Canada, and the Society for Academic Emergency Medicine. The focus of this work is treatment of women with acute uncomplicated cystitis and pyelonephritis, diagnoses limited in these guidelines to premenopausal, non-pregnant women with no known urological abnormalities or co-morbidities. The issues of in vitro resistance prevalence and the ecological adverse effects of antimicrobial therapy (collateral damage) were considered as important factors in making optimal treatment choices and thus are reflected in the rankings of recommendations.  

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*Every 12 to 18 months following publication, IDSA reviews its guidelines to determine whether an update is required. This guideline was last reviewed and deemed current as of 07/2013.

Recommendations

I. What Is the Optimal Treatment for Acute Uncomplicated Cystitis?

Recommendations

  1. Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is an appropriate choice for therapy due to minimal resistance and propensity for collateral damage (defined above) and efficacy comparable to 3 days of trimethoprim-sulfamethoxazole (A-I).
  2. Trimethoprim-sulfamethoxazole (160/800 mg [1 double-strength tablet] twice-daily for 3 days) is an appropriate choice for therapy, given its efficacy as assessed in numerous clinical trials, if local resistance rates of uropathogens causing acute uncomplicated cystitis do not exceed 20% or if the infecting strain is known to be susceptible (A-I).
    1. The threshold of 20% as the resistance prevalence at which the agent is no longer recommended for empirical treatment of acute cystitis is based on expert opinion derived from clinical, in vitro, and mathematical modeling studies (B-III).
    2. In some countries and regions, trimethoprim (100 mg twice daily for 3 days) is the preferred agent and is considered equivalent to trimethoprim-sulfamethoxazole on the basis of data presented in the original guideline (A-III) [1].
    3. Data are insufficient to make a recommendation for other cystitis antimicrobials as to what resistance prevalence should be used to preclude their use for empirical treatment of acute cystitis.
  3. Fosfomycin trometamol (3 g in a single dose) is an appropriate choice for therapy where it is available due to minimal resistance and propensity for collateral damage, but it appears to have inferior efficacy compared with standard short-course regimens according to data submitted to the US Food and Drug Administration (FDA) and summarized in the Medical Letter (A-I)
  4. Pivmecillinam (400 mg bid for 3–7 days) is an appropriate choice for therapy in regions where it is available (availability limited to some European countries; not licensed and/or available for use in North America), because of minimal resistance and propensity for collateral damage, but it may have inferior efficacy compared with other available therapies (A-I).
  5. The fluoroquinolones, ofloxacin, ciprofloxacin, and levofloxacin, are highly efficacious in 3-day regimens (A-I) but have a propensity for collateral damage and should be reserved for important uses other than acute cystitis and thus should be considered alternative antimicrobials for acute cystitis (A-III).
  6. β-Lactam agents, including amoxicillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil, in 3–7-day regimens are appropriate choices for therapy when other recommended agents cannot be used (B-I). Other β-lactams, such as cephalexin, are less well studied but may also be appropriate in certain settings (B-III). The β-lactams generally have inferior efficacy and more adverse effects, compared with other UTI antimicrobials (B-I). For these reasons, β-lactams other than pivmecillinam should be used with caution for uncomplicated cystitis.
  7. Amoxicillin or ampicillin should not be used for empirical treatment given the relatively poor efficacy, as discussed in the 1999 guidelines [1] and the very high prevalence of antimicrobial resistance to these agents worldwide [8–11] (A-III).

II. What Is the Treatment for Acute Pyelonephritis?

Recommendations

  1. In patients suspected of having pyelonephritis, a urine culture and susceptibility test should always be performed, and initial empirical therapy should be tailored appropriately on the basis of the infecting uropathogen (A-III).
  2. Oral ciprofloxacin (500 mg twice daily) for 7 days, with or without an initial 400-mg dose of intravenous ciprofloxacin, is an appropriate choice for therapy in patients not requiring hospitalization where the prevalence of resistance of community uropathogens to fluoroquinolones is not known to exceed 10% (A-I). If an initial one-time intravenous agent is used, a long-acting antimicrobial, such as 1 g of ceftriaxone or a consolidated 24-h dose of an aminoglycoside, could be used in lieu of an intravenous fluoroquinolone (B-III). If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial 1-time intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (B-III) or a consolidated 24-h dose of an aminoglycoside, is recommended (B-III).
    1. Data are insufficient to make a recommendation about what fluoroquinolone resistance level requires an alternative agent in conjunction with or to replace a fluoroquinolone for treatment of pyelonephritis.
  3. A once-daily oral fluoroquinolone, including ciprofloxacin (1000 mg extended release for 7 days)or levofloxacin (750 mg for 5 days), is an appropriate choice for therapy in patients not requiring hospitalization where the prevalence of resistance of community uropathogens is not known to exceed 10% (B-II). If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (B-III) or a consolidated 24-h dose of an aminoglycoside, is recommended (B-III).
  4. Oral trimethoprim-sulfamethoxazole (160/800 mg [1 double-strength tablet] twice-daily for 14 days) is an appropriate choice for therapy if the uropathogen is known to be susceptible (A-I). If trimethoprim-sulfamethoxazole is used when the susceptibility is not known, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (B-II) or a consolidated 24-h dose of an aminoglycoside, is recommended (B-III).
  5. Oral β-lactam agents are less effective than other available agents for treatment of pyelonephritis (B-III). If an oral β-lactam agent is used, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (B-II) or a consolidated 24-h dose of an aminoglycoside, is recommended (B-III).
    1. Data are insufficient to modify the previous guideline recommendation for a duration of therapy of 10–14 days for treatment of pyelonephritis with a β-lactam agent.
  6. Women with pyelonephritis requiring hospitalization should be initially treated with an intravenous antimicrobial regimen, such as a fluoroquinolone; an aminoglycoside, with or without ampicillin; an extended-spectrum cephalosporin or extended-spectrum penicillin, with or without an aminoglycoside; or a carbapenem. The choice between these agents should be based on local resistance data, and the regimen should be tailored on the basis of susceptibility results (B-III).

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