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Diagnosis and Management of Lower Urinary Tract Infection

Guidelines Being Compared:

  1. 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]
  2. Infectious Diseases Society of America/European Society for Microbiology and Infectious Diseases (IDSA/ESMI). 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(5):e103-20. [61 references]
  3. Society of Obstetricians and Gynaecologists of Canada (SOGC). Recurrent urinary tract infection. J Obstet Gynaecol Can 2010 Nov;32(11):1082-90. [82 references]

A direct comparison of the recommendations presented in the above guidelines for the diagnosis and treatment of acute uncomplicated lower UTI and recurrent UTI in women is provided in the tables below. The diagnosis and management of pyelonephritis is beyond the scope of this synthesis.

Areas of Agreement

Diagnosis

ACOG and SOGC agree that common signs and symptoms of acute uncomplicated lower UTI include: dysuria, frequent and urgent urination, suprapubic pain or tenderness, and possibly hematuria. There is also agreement that the presence of vaginal symptoms (e.g., vaginitis, urethritis) should prompt alternative diagnoses. ACOG—the only group to provide explicit recommendations for diagnosis—states that for women without a history of a laboratory-confirmed UTI, an office visit for urinalysis or dipstick testing is appropriate. However, women with frequent recurrences and prior confirmation by diagnostic tests who are aware of their symptoms may be empirically treated. For women who undergo laboratory evaluation, ACOG states that dipstick testing is a rapid and inexpensive method. While urine culture is generally not necessary, ACOG recommends that negative dipstick results should be followed-up by a urine culture, urinalysis, or both. The IDSA/ESMI guideline does not address diagnosis.

Treatment for Acute Uncomplicated Lower UTI

Agents cited as appropriate by both ACOG and IDSA/ESMI include: TMP-SMX (160/800 mg tablet twice daily for 3 days; not recommended in areas where local resistance rates exceed 20%); nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days); and fosfomycin trometamol (3 g powder single dose). ACOG also recommends TMP alone (100 mg, twice daily for 3 days); IDSA/ESMI also recommends pivmecillinam (400 mg bid for 3–7 days), a beta-lactam, in regions where it is available (not licensed and/or available for use in North America). According to ACOG, TMP-SMX for 3 days is the preferred therapy. IDSA/ESMI does not designate any of the four antimicrobials it recommends as preferred, but does note that fosfomycin and pivmecillinam have lower efficacy than other recommended agents.

ACOG and IDSA/ESMI agree that while fluoroquinolones are highly effective in 3-day regimens, resistance to this class of antimicrobials is increasing and overuse will hinder their efficacy for treating important infections other than acute cystitis, including pyelonephritis. For this reason, ACOG recommends against prescribing fluoroquinolones as first-line agents in areas where resistance prevalence to TMP-SMX is low; IDSA/ESMI recommends that fluoroquinolones be considered for acute cystitis only if a recommended antimicrobial cannot be used due to factors such as availability, allergy history, or tolerance.

The guideline developers agree that beta-lactam agents (with the exception of pivmecillinam, which IDSA/ESMI recommends) generally are less effective than other UTI antimicrobials and should not be used as first-line agents. There is consensus that the beta-lactam antibiotics amoxicillin and ampicillin should not be used for empirical treatment given the relatively poor efficacy and the very high prevalence of antimicrobial resistance to these agents worldwide.

Prevention of Recurrent UTI

ACOG and SOGC address antibiotic therapy for the prevention of recurrent UTI, and agree that the primary strategies generally considered are: continuous antimicrobial prophylaxis, post-coital prophylaxis, and patient-initiated self-treatment. For women with frequent recurrences (SOGC specifies ≥2 UTIs in 6 months or ≥3 UTIs in 12 months), the groups agree that it is appropriate to offer continuous daily antibiotic prophylaxis for a 6- to 12-month period. With regard to selection of the antibiotic, both groups recommend nitrofurantoin, TMP, TMP/SMX, and fluoroquinolones. SOGC also cites cephalexin; ACOG also cites fosfomycin tromethamine.

The groups agree that women with recurrences associated with sexual intercourse may be offered postcoital prophylaxis—a single antibiotic dose taken after sexual intercourse—as an alternative to continuous therapy. There is further agreement that women with recurrent UTIs are often aware of symptom onset, and that self-initiated 3-day course of antibiotic therapy can be a viable option for these patients. SOGC specifies that self-treatment should be restricted to compliant and motivated patients in whom recurrent UTIs have been clearly documented. The groups agree that if symptoms do not improve within 48 hours, women should contact their provider for a clinical evaluation. SOGC further recommends that prophylaxis for recurrent UTI should not be undertaken until a negative culture 1 to 2 weeks after treatment has confirmed eradication of the UTI.

With regard to non-antibiotic interventions, ACOG and SOGC agree that cranberry products are useful for prophylaxis of recurrent UTI, and that sexually active women who suffer from recurrent UTIs and use spermicide should be encouraged to consider using an alternative form of contraception. The guideline developers also address the use of vaccines and probiotics (vaginal lactobacilli application) for recurrent UTI, which both groups found insufficient evidence to recommend. Other interventions addressed by ACOG include aggressive hydration, postcoital voiding, and douching/wiping techniques, all of which it found insufficient evidence to recommend.

Areas of Difference

Prevention of Recurrent UTI

With regard to non-antibiotic interventions for prevention recurrent UTI, ACOG and SOGC address estrogen therapy. According to ACOG, large, randomized trials are required before exogenous estrogen therapy can be conclusively recommended for UTI recurrence prevention. SOGC, in contrast, states that vaginal estrogen should be offered to postmenopausal women who experience recurrent UTIs. They note, however, that studies have provided insufficient evidence for recommending a particular type or form of vaginal estrogen.

An additional intervention addressed by only SOGC is acupuncture, which SOGC states may be considered as an alternative in the prevention of recurrent UTIs in women who are unresponsive to or intolerant of antibiotic prophylaxis.

Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Diagnosis and management of lower urinary tract infection. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Jan (revised 2012 Mar). [cited YYYY Mon DD]. Available: http://www.guideline.gov.