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Guideline Summary
Guideline Title
Treatment of urinary tract infections in nonpregnant women.
Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Treatment of urinary tract infections in nonpregnant women. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2008 Mar. 10 p. (ACOG practice bulletin; no. 91).  [51 references]
Guideline Status

This is the current release of the guideline.

The American College of Obstetricians and Gynecologists (ACOG) reaffirmed the currency of this guideline in 2012.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • August 15, 2013 – Fluoroquinolone Antibacterial Drugs External Web Site Policy: The U.S. Food and Drug Administration (FDA) has required the drug labels and Medication Guides for all fluoroquinolone antibacterial drugs be updated to better describe the serious side effect of peripheral neuropathy. This serious nerve damage potentially caused by fluoroquinolones may occur soon after these drugs are taken and may be permanent.

Scope

Disease/Condition(s)

Urinary tract infections

  • Acute bacterial cystitis
  • Acute pyelonephritis
Guideline Category
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Obstetrics and Gynecology
Urology
Intended Users
Physicians
Guideline Objective(s)
  • To aid practitioners in making decisions about appropriate obstetric and gynecologic care
  • To address the diagnosis, treatment, and prevention of uncomplicated acute bacterial cystitis and acute bacterial pyelonephritis in nonpregnant women
Target Population

Nonpregnant women with uncomplicated urinary tract infections (UTIs)

Note: Women with complicated UTIs (e.g., in patients with diabetes mellitus, abnormal anatomy, prior urologic surgery, a history of renal stones, an indwelling catheter, spinal cord injury, immunocompromise, or in pregnant patients) are a heterogeneous group of conditions beyond the scope of this guideline.

Interventions and Practices Considered

Evaluation and Diagnosis

  1. Differential diagnosis: acute bacterial cystitis versus acute pyelonephritis
    • Clinical history and physical examination
    • Laboratory evaluation of bacteriuria and pyuria
      • Urine dipstick testing
      • Urine culture or urinalysis
  2. Risk factor assessment for urinary tract infection (UTI) in premenopausal and postmenopausal women
  3. Risk factor assessment for recurrent UTI
  4. Imaging of the urinary tract (not recommended routinely for uncomplicated UTIs)
  5. Screening for asymptomatic bacteriuria in nonpregnant, premenopausal women (considered but specifically not recommended)

Treatment and Management

  1. Antimicrobial regimens for uncomplicated UTIs (3-day vs. 7-day)
    • Trimethoprim-sulfamethoxazole
    • Trimethoprim
    • Ciprofloxacin
    • Levofloxacin
    • Norfloxacin
    • Gatifloxacin
    • Nitrofurantoin macrocrystals and nitrofurantoin monohydrate macrocrystals
    • Fosfomycin tromethamine
  2. Use of 14-day antimicrobial regimens for acute pyelonephritis
  3. Management of recurrent UTI
    • Prophylactic or intermittent antimicrobial therapy
    • Cranberry juice
    • Methenamine salts (not sufficient evidence for use)
  4. Treatment of UTIs in postmenopausal women
Major Outcomes Considered
  • Incidence of acute bacterial cystitis
  • Incidence of acute pyelonephritis
  • Incidence of recurrent urinary tract infections
  • Effectiveness of antimicrobial therapy (clinical response and bacterial eradication rates)
  • Sensitivity and specificity of diagnostic tests
  • Adverse effects of treatment

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

2008 Original Guideline

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and April 2007. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

2012 Reaffirmation

The NCBI database was searched from 2008 to 2012. Committee members conducted a literature search with the assistance from the ACOG Resource Center staff who routinely perform the Practice Bulletin literature searches.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I Evidence obtained from at least one properly designed randomized controlled trial.

II-1 Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

2008 Original Guideline

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

2012 Reaffirmation

The Committee on Practice Bulletins - Gynecology met in March 2012 and reaffirmed this document. A committee member reviewed the document and new literature on the topic. The document was then reviewed by the committee and the committee agreed that it is current and accurate.

Rating Scheme for the Strength of the Recommendations

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

Recommendations

Major Recommendations

The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):

  • Screening for and treatment of asymptomatic bacteriuria is not recommended in nonpregnant, premenopausal women.
  • Resistance rates higher than 15 to 20% necessitate a change in antibiotic class.
  • In all cases of acute pyelonephritis, whether treatment is on an inpatient or outpatient basis, 14 days of total antimicrobial therapy should be completed.
  • A 3-day antimicrobial regimen is the preferred treatment duration for uncomplicated acute bacterial cystitis in women, including women aged 65 years and older.

The following conclusion is based on limited or inconsistent evidence (Level B):

  • The initial treatment of a symptomatic lower urinary tract infection (UTI) with pyuria or bacteriuria or both does not require a urine culture.

The following conclusions are based primarily on consensus and expert opinion (Level C):

  • Beta-lactams, such as first-generation cephalosporins and amoxicillin, are less effective in the treatment of acute uncomplicated cystitis than those antimicrobials listed in the Table below.
  • To diagnose bacteriuria, decreasing the colony count to 1,000 to 10,000 bacteria per milliliter in symptomatic patients will improve the sensitivity without significantly compromising specificity.

Table. Treatment Regimens for Uncomplicated Acute Bacterial Cystitis

Antimicrobial Agent Dose Adverse Events
Trimethoprim–sulfamethoxazole One tablet (160 mg trimethoprim–800 mg sulfamethoxazole), twice daily for 3 days Fever, rash, photosensitivity, neutropenia, thrombocytopenia, anorexia, nausea and vomiting, pruritus, headache, urticaria, Stevens–Johnson syndrome, and toxic epidermal necrosis
Trimethoprim 100 mg, twice daily for 3 days Rash, pruritus, photosensitivity, exfoliative dermatitis, Stevens–Johnson syndrome, toxic epidermal necrosis, and aseptic meningitis
Ciprofloxacin 250 mg, twice daily for 3 days Rash, confusion, seizures, restlessness, headache, severe hypersensitivity, hypoglycemia, hyperglycemia, and Achilles tendon rupture (in patients older than 60 years)
Levofloxacin 250 mg, once daily for 3 days Same as for ciprofloxacin
Norfloxacin 400 mg, twice daily for 3 days Same as for ciprofloxacin
Gatifloxacin 200 mg, once daily for 3 days Same as for ciprofloxacin
Nitrofurantoin macrocrystals 50 to 100 mg, four times daily for 7 days Anorexia, nausea, vomiting, hypersensitivity, peripheral neuropathy, hepatitis, hemolytic anemia, and pulmonary reactions
Nitrofurantoin monohydrate crystals 100 mg, twice daily for 7 days Same as for nitrofurantoin macrocrystals
Fosfomycin tromethamine 3 g dose (powder) single dose Diarrhea, nausea, vomiting, rash, and hypersensitivity

Definitions:

Grades of Evidence

I Evidence obtained from at least one properly designed randomized controlled trial.

II-1 Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendation

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Accurate diagnosis and appropriate management of urinary tract infections in nonpregnant women

Potential Harms

Adverse events associated with antimicrobial treatment regimens (see Table 1 in the original guideline document).

Qualifying Statements

Qualifying Statements

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
Foreign Language Translations
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Treatment of urinary tract infections in nonpregnant women. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2008 Mar. 10 p. (ACOG practice bulletin; no. 91).  [51 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2008 Mar (reaffirmed 2012)
Guideline Developer(s)
American College of Obstetricians and Gynecologists - Medical Specialty Society
Source(s) of Funding

American College of Obstetricians and Gynecologists (ACOG)

Guideline Committee

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins - Gynecology

Composition of Group That Authored the Guideline

Not stated

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

The American College of Obstetricians and Gynecologists (ACOG) reaffirmed the currency of this guideline in 2012.

Guideline Availability

Electronic copies: None available

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site External Web Site Policy.

Availability of Companion Documents

Proposed performance measures are included in the original guideline document.

Patient Resources

The following is available:

  • Urinary tract infections. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG); 2006.

Electronic copies: Available from the American College of Obstetricians and Gynecologists (ACOG) Web site External Web Site Policy. Copies are also available in Spanish.

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on July 30, 2008. The information was verified by the guideline developer on August 20, 2008. This summary was updated by ECRI Institute on October 25, 2013 following the U.S. Food and Drug Administration advisory on Fluoroquinolone Antibacterial Drugs. The currency of the guideline was reaffirmed by the developer in 2012 and this summary was updated by ECRI Institute on March 7, 2014.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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