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  • Guideline Summary
  • NGC:008682
  • 1999 Jun (revised 2011 Jun)

Urinary tract infection.

University of Michigan Health System. Urinary tract infection. Ann Arbor (MI): University of Michigan Health System; 2011 Jun. 8 p. [11 references]

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. UMHS urinary tract infection guideline. Ann Arbor (MI): University of Michigan Health System; 2005 May. 9 p.

The University of Michigan Health System released a minor revision in September 2014 to include information from a Cochrane review that was released after the May 2011 publication of this guideline.

Age Group

UMLS Concepts (what is this?)

SNOMEDCT_US
Amoxicillin (27658006), Amoxicillin (372687004), Antibiotic (255631004), Antibiotic prophylaxis (422181004), Bacteriuria (61373006), Ciprofloxacin (372840008), Ciprofloxacin (392412000), Ciprofloxacin (7577004), Dysuria (49650001), Levofloxacin (387552007), Levofloxacin (96087006), Manual pelvic examination (35025007), Microscopic urinalysis (127800008), Nitrofurantoin (373543005), Nitrofurantoin (85343003), Ofloxacin (387551000), Ofloxacin (96086002), Physical assessment (302199004), Physical assessment (5880005), Physical assessment (81375008), Pregnancy (289908002), Pyelonephritis (45816000), Pyuria (275765006), Pyuria (4800001), Quinolone -class of antibiotic- (37084008), Quinolone -class of antibiotic- (372722000), Recurrent urinary tract infection (197927001), Self-care interventions (384758001), Sulfamethoxazole + trimethoprim (398731002), Sulfamethoxazole + trimethoprim (703745000), Triage (225390008), Triage: telephone (386479004), Urinalysis (167217005), Urinalysis (27171005), Urinary tract infectious disease (68566005), Urine dipstick for leukocyte esterase (252385000), Urine dipstick for nitrite (302791006), Urine for culture (117010004), Urine for culture (275885001)

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.

  • May 12, 2016 – Fluoroquinolone Antibacterial Drugs External Web Site Policy: The U.S. Food and Drug Administration (FDA) is advising that the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with sinusitis, bronchitis, and uncomplicated urinary tract infections who have other treatment options. For patients with these conditions, fluoroquinolones should be reserved for those who do not have alternative treatment options.

Major Recommendations

Note from the University of Michigan Health System (UMHS) and the National Guideline Clearinghouse (NGC): The following guidance was current as of June 2011. Because UMHS occasionally releases minor revisions to its guidance based on new information, users may wish to consult the original guideline document External Web Site Policy for the most current version.

Note from NGC: The following key points summarize the content of the guideline. Refer to the full text of the original guideline document for detailed information on diagnosis, treatment, and medications.

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

Diagnosis

  • History. Diagnosis is made primarily by history. In women with dysuria and frequency, in the absence of vaginitis, the diagnosis is urinary tract infection (UTI) 80% of the time [IC].
  • Phone triage. In women with prior history of uncomplicated UTI's, consider phone triage [IIC].
  • Urinalysis. Urinalysis for detection of pyuria by dipstick or microscope has a sensitivity of 80%-90% and a specificity of 50% for predicting UTI [IB].
  • No urine culture (UC). UC is NOT indicated in the vast majority of UTIs [IIIC]. UC has a sensitivity of 50% (if threshold for positive is >105 organisms), sensitivity can be increased to >90% if threshold is >102 organisms. Consider UC only in recurrent UTI or in the presence of complicating factors.

Treatment

  • First line:
    • Three days of trimethoprim/sulfa [IA]
    • Five to seven days nitrofurantoin [IA]
  • Second line
    • Three days of quinolone (contraindicated in pregnancy) [IA]
    • Seven days amoxicillin, 1° cephalosporin [IA]

Follow-up

  • No tests if asymptomatic. No laboratory follow-up is necessary if asymptomatic [IIIB].
  • For recurrent UTIs. In patients with recurrent UTIs (>3/year)
    • Consider antibiotic prophylaxis/self-initiated therapy [IIA]
    • Urologic structural evaluation rarely indicated [IIID]

Definitions:

Levels of Evidence

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational trials
  4. Opinion of expert panel

Strength of Recommendation

  1. Generally should be performed
  2. May be reasonable to perform
  3. Generally should not be performed

Clinical Algorithm(s)

An algorithm is provided in the original guideline document for the diagnosis and management of urinary tract infection (UTI) in adult non-pregnant women.

Disease/Condition(s)

  • Uncomplicated urinary tract infection (UTI)
  • Recurrent UTI
  • Acute uncomplicated pyelonephritis
  • Asymptomatic bacteriuria
  • UTI in pregnancy

Guideline Category

Diagnosis

Evaluation

Management

Prevention

Risk Assessment

Treatment

Clinical Specialty

Family Practice

Infectious Diseases

Internal Medicine

Nephrology

Obstetrics and Gynecology

Preventive Medicine

Urology

Intended Users

Advanced Practice Nurses

Nurses

Physician Assistants

Physicians

Guideline Objective(s)

To implement a cost-effective strategy for uncomplicated urinary tract infection (UTI) in women

Target Population

Adult women with uncomplicated urinary tract infection

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Diagnosis based on symptoms and patient history
  2. Phone triage
  3. Dipstick urinalysis for leukocyte esterase
  4. Nitrite testing by dipstick
  5. Microscopic examination of unstained, centrifuged urine under 40x power
  6. Urine culture (not indicated routinely)
  7. Pelvic examination and physical exam

Treatment/Management

  1. Antibiotic treatment
    • First-line: trimethoprim/sulfamethoxazole [TMP/SMX] or nitrofurantoin
    • Second-line: ciprofloxacin, levofloxacin, amoxicillin, or first-generation cephalosporin
  2. Follow-up urinalysis and urine cultures
  3. Telephone triage and nurse-managed evaluation
  4. Prophylaxis: continuous antibiotic therapy, cranberry juice, self-initiated therapy
  5. Urologic structural evaluation for recurrent infection (generally not indicated)

Major Outcomes Considered

  • Assessment of diagnostic tests (sensitivity, specificity, predictive value, validity)
  • Response to treatment (cure rate, symptom relief)
  • Drug side effects

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

Searches of Unpublished Data

Description of Methods Used to Collect/Select the Evidence

The literature search for this update began with the results of the literature search performed for the earlier version of this guideline (1/1/91-6/30/98; 7/1/98 to 8/31/04). However, instead of beginning the search with literature in 2004, the guideline team accepted the search strategy and results for the search performed through 4/30/07 for the American College of Obstetricians and Gynecologist (ACOG) Practice Bulletin No. 91, Treatment of urinary tract infections in nonpregnant women (see "Related National Guidelines" in the original guideline document).

The additional search for the update of this guideline was conducted prospectively on Medline using the major keywords of: urinary tract infections; guidelines, controlled trials, and cohort studies; published from 1/1/07 to 4/30/10; humans, adult women. Specific searches were performed for: predictive value of tests, diagnosis (other than predictive value of tests), treatment, uncomplicated UTI – treatment, pregnancy, postmenopausal women – treatment, recurrent UTI, self-initiated therapy, group B strep and non-pregnant women, telephone triage – nursing protocol, other treatment, other references to UTI.

The search was conducted in components each keyed to a specific causal link in a formal problem structure (available upon request). The search was supplemented with recent clinical trials known to expert members of the panel. Negative trials were specifically sought. The search was a single cycle.

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

Levels of Evidence

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational trials
  4. Opinion of expert panel

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

Conclusions were based on prospective randomized controlled trials (RCTs) if available, to the exclusion of other data; if RCTs were not available, observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation, expert opinion was used to estimate effect size.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Strength of Recommendation

  1. Generally should be performed
  2. May be reasonable to perform
  3. Generally should not be performed

Cost Analysis

Urinary tract infections (UTI) are estimated to account for over 7 million office visits per year, at a cost of over $1 billion.

Establishing a cost-effective strategy for the diagnosis and treatment of UTI is important because of its high incidence.

Acute uncomplicated cystitis in women historically has been treated with longer (7-10 day) courses of antibiotics. However, studies have found shorter courses (3-5 days) of oral antibiotics to be as effective as traditional courses. A review of 28 treatment trials of adult women with uncomplicated cystitis concluded that no benefit was achieved by increasing the length of therapy beyond 5 days. The advantages of shorter course therapy include decreased costs of antibiotics, improved patient compliance and decreased adverse effects of antibiotic treatment (e.g., amoxicillin-associated vaginitis).

Of the 3-day regimens, trimethoprim/sulfamethoxazole (TMP/SMX) is more effective and less expensive than nitrofurantoin, cefadroxil, or amoxicillin for treatment of uncomplicated cystitis in women. Quinolones have also been shown to be effective in 3-day courses; however, cost is increased significantly over TMP/SMX combinations. In addition, overuse of quinolones has raised concerns about resistance. Ciprofloxacin, 250 mg BID for 3 days, appears to be the most cost effective quinolone regimen. Therefore, the optimal treatment of uncomplicated UTI in patients who are not allergic or sensitive is 3 days of TMP/SMX.

Cost-effectiveness analyses have shown cost savings for quinolones over TMP/SMX when resistance to TMP/SMX exceeds 22%. However, this study was performed prior to the rapid spread of quinolone resistance.

For more details, refer to the Annotated References section of the original guideline document.

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

Drafts of this guideline were reviewed in clinical conferences and by distribution for comment within departments and divisions of the University of Michigan Medical School to which the content is most relevant: Family Medicine, General Medicine, General Obstetrics & Gynecology, and Infectious Diseases. The Executive Committee for Clinical Affairs of the University of Michigan Hospitals and Health Centers endorsed the final version.

Type of Evidence Supporting the Recommendations

The type of evidence is identified and graded for the most significant recommendations (see the "Major Recommendations" field).

Conclusions were based on prospective randomized controlled trials (RCTs) if available, to the exclusion of other data; if RCTs were not available, observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation, expert opinion was used to estimate effect size.

Potential Benefits

  • Appropriate utilization of clinical care resources and good clinical outcomes
  • Specific benefits of shorter course (<5 days) antibiotic therapy include:
    • Decreased costs of antibiotics
    • Improved patient compliance
    • Decreased adverse effects of antibiotic treatments (e.g., amoxicillin-associated vaginitis)
  • Specific benefits of a phone triage guideline
    • Decreased cost
    • Increased appropriate antibiotic use without any increase in adverse outcomes
  • Prophylactic antibiotic use has been shown to reduce frequency of UTI in sexually active women.

Potential Harms

  • Adverse events from antibiotic use are generally mild, although women vary in their evaluation of the impact of various side effects (i.e., oral or vaginal candidiasis may be seen as a severe side effect by some, mild by others).
  • Adverse effects associated with the use of trimethoprim/sulfamethoxazole (TMP/SMX) increase markedly if treatment is continued past 3 days.
  • Amoxicillin is associated with vaginitis.
  • Risk of development of antibiotic resistance (secondary to recurrent urinary tract infections)

Contraindications

Quinolones are contraindicated in pregnancy.

Qualifying Statements

These guidelines should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific clinical procedure or treatment must be made by the physician in light of the circumstances presented by the patient.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Clinical Algorithm

Staff Training/Competency Material

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

Getting Better

Living with Illness

IOM Domain

Effectiveness

Patient-centeredness

Bibliographic Source(s)

University of Michigan Health System. Urinary tract infection. Ann Arbor (MI): University of Michigan Health System; 2011 Jun. 8 p. [11 references]

Adaptation

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

Date Released

1999 Jun (revised 2011 Jun)

Guideline Developer(s)

University of Michigan Health System - Academic Institution

Source(s) of Funding

University of Michigan Health System

Guideline Committee

Urinary Tract Infection Guideline Team

Composition of Group That Authored the Guideline

Team Leader: Steven E. Gradwohl, MD, General Medicine

Team Members: Catherine M. Bettcher, MD, Family Medicine; Carol E. Chenoweth, MD, Infectious Diseases; R. Van Harrison, PhD, Medical Education; Lauren B. Zoschnick, MD, Obstetrics & Gynecology

Guidelines Oversight Team: Connie J. Standiford, MD; Grant M. Greenberg, MD, MA, MHSA; R. Van Harrison, PhD

Financial Disclosures/Conflicts of Interest

The University of Michigan Health System endorses the Guidelines of the Association of American Medical Colleges and the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant relationships with commercial companies whose products or services are discussed. Disclosure of a relationship is not intended to suggest bias in the information presented, but is made to provide readers with information that might be of potential importance to their evaluation of the information.

Team Member Company Relationship
Catherine M. Bettcher, MD (None) (None)
Carol E. Chenoweth, MD (None) (None)
Steven E. Gradwohl, MD (None) (None)
R. Van Harrison, PhD (None) (None)
Lauren B. Zoschnick, MD (None) (None)

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. UMHS urinary tract infection guideline. Ann Arbor (MI): University of Michigan Health System; 2005 May. 9 p.

The University of Michigan Health System released a minor revision in September 2014 to include information from a Cochrane review that was released after the May 2011 publication of this guideline.

Guideline Availability

Electronic copies: Available from the University of Michigan Health System Web site External Web Site Policy.

Availability of Companion Documents

Continuing Medical Education (CME) information is available from the University of Michigan Health System Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on August 21, 2000. The information was verified by the guideline developer on November 22, 2000. This summary was updated by ECRI on August 4, 2005. The updated information was verified by the guideline developer on August 10, 2005. This summary was updated by ECRI Institute on July 28, 2008 following the U.S. Food and Drug Administration advisory on fluoroquinolone antimicrobial drugs. This NGC summary was updated by ECRI Institute on December 9, 2011. This summary was updated by ECRI Institute on October 25, 2013 following the U.S. Food and Drug Administration advisory on Fluoroquinolone Antibacterial Drugs. This summary was updated by ECRI Institute on May 18, 2016 following the U.S. Food and Drug Administration advisory on Fluoroquinolone Antibacterial Drugs.

Copyright Statement

This NGC summary is based on the original guideline, which is copyrighted by the University of Michigan Health System (UMHS).

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