Professional Documents
Culture Documents
Clinical Background
Clinical Problem Antibiotic treatment should be prescribed only
and Clinical Dilemma for as long as necessary to be effective.
Recurrent UTI’s may be managed better by self-
For more information call initiated therapy or prophylaxis than by
GUIDES: 936-9771 Incidence
continuing to treat each case emergently. This
Urinary tract infections (UTI) are estimated to guideline provides an approach to uncomplicated
© Regents of the account for over 7 million office visits per year, UTI that results in good clinical outcomes and
University of Michigan utilizes clinical care resources appropriately.
at a cost of over $1 billion. Up to 40% of
women will develop UTI at least once during
their lives, and a significant number of these
These guidelines should not be
construed as including all proper
women will have recurrent urinary tract Rationale for Recommendations
methods of care or excluding infections.
other acceptable methods of care The rationale for recommendations addresses:
reasonably directed to obtaining
the same results. The ultimate Cost-Effective Strategy • Risk factors
judgment regarding any specific
clinical procedure or treatment Establishing a cost-effective strategy for the • Complicating factors
must be made by the physician in
diagnosis and treatment of UTI is important • Uncomplicated UTI
light of the circumstances • Recurrent UTI’s
presented by the patient. because of its high incidence. Laboratory tests
should be ordered only when the results are • Asymptomatic bacteriuria
likely to alter the process or outcome of care. • Acute uncomplicated pyelonephritis
• UTI in pregnancy
(Continued on page 3)
1
Figure 1. Diagnosis and Management of UTI
no no
yes
no
Consider:
Urinalysis microscopic
negative • pelvic exam
dipstick results
• urine culture
positive
Complicating conditions
• Complicating factors (Table 2)? See
complicating factors section
UTI uncomplicated? no • Recurrent UTI's (>3/yr)? See recurrent UTI
section
• Pyelo symptoms? See pyelonephritis section
yes • Pregancy? See pregnancy section
• Re-visit
• Consider:
Symptoms persist? yes
- Pelvic exam
- UC with sensitivities
no * Levels of Evidence:
A = randomized controlled trials
B = controlled trials, no randomization
Follow-up PRN C = observational trials
(No follow-up UA or UC necessary) [B*] D = opinion of expert panel
Table 1. Laboratory Charges Table 2. Complicating Factors Table 3. Treatment Regimens and Cost*
(M-Labs)
Diabetes Mellitus First Line: Brand Generic
Immunosuppression Trimethoprim / Sulfa DS BID x 3 days $11 $4
Urinalysis - dipstick $19 Urologic Structural / Second Line (preferred order):
Functional Abnormality Ciprofloxacin 1 250 mg BID x 3 days $27 $4
Urinalysis - microscopic Nephrolithiasis present Levofloxacin1, 2 250 mg daily x 3 days $52 N/A
(complete) $15 Recent Hospitalization/ Amoxicillin 500 TID x 7 days $7 $5
Nursing home Nitrofurantoin 100 QID x 7 days $59 $31
Urine culture $52 Catheter Macrobid 100 mg BID x 7 days $31 $22
Symptoms for > 7 days
* Cost = Average wholesale price based -10% for brand products and Maximum Allowable Cost (MAC) + $3 for generics on 30-day supply or
less, Amerisource AWP 01/05 & Blue Cross Blue Shield of Michigan Mac List, 01/31/05.
1
Flouoroquinolones increase the risk of tendon rupture in those over age 60, in kidney, heart, and lung transplant recipients, and with use of
concomitant steroid therapy.
2
Moderate to severe photosensitivity/phototoxicity may occur
Prophylactic antibiotic use, either daily or used only Asymptomatic Bacteriuria (ASB)
postcoitally, has been shown to reduce frequency of UTI in
sexually active women. The benefits accrue only during Diagnosis. Asymptomatic bacteriuria is the presence of
active prophylaxis. Once antibiotics are discontinued, UTIs "significant" numbers of bacteria in the urine without the
occur at the same rate as in placebo-treated sexually active presence of symptoms. Significant bacteriuria is defined as
women. Adverse events from antibiotic use are generally >105 CFU/ml of urine. The presence of one organism per
mild, although women vary in their evaluation of the high-powered field in a clean-catch, midstream, unspun
impact of various side effects (i.e., oral or vaginal urine sample represents significant bacteriuria (equivalent
candidiasis may be seen as a severe side effect by some, to >105 CFU/ml).
mild by others.)
Patients with chronic indwelling catheters are at particular
Commonly use prophylactic antibiotics include risk for developing bacteriuria. The risk of UTI can be
cotrimoxazole, nitrofurantoin, cephalexin, or a quinolone. decreased by using catheters only when necessary, insertion
Nitrofurantoin appears to have the highest withdrawal rate, of the catheter under aseptic technique, use of a closed
followed by cephalexin. It appears that post-coital drainage system, avoidance of irrigation, and change of
prophylaxis is as effective as daily intake. Quinolones catheters every 2-3 weeks. Intermittent catheterization and
should be avoided, given concerns about antibiotic external catheters are associated with fewer infections than
resistance, as well as higher cost. When used, they may be are indwelling catheters.
considered for weekly dosing. They are contra-indicated in
pregnancy. Asymptomatic bacteriuria occurs in 40% of elderly adults,
especially in nursing homes. In controlled studies that
In regards to the use of other prophylactic measures, some address issues of underlying illness, asymptomatic
studies have shown that cranberry juice or cranberry tablets bacteriuria does not increase risk of death.
can significantly reduce the annual incidence of UTIs in
sexually active women with a history of recurrent UTIs. Treatment. Screening and/or treatment of asymptomatic
[A]. The best dose is unknown, but one trial suggests that bacteriuria in most settings is not recommended because of
tablets are equally as effective as juice, and cost less. No unproved efficacy, risk of side effects from antibiotics,
trials that suggest cranberry in any form is useful in the development of antibiotic resistance, and cost issues.
treatment of UTI.
Treatment of asymptomatic bacteriuria is recommended in
Only poor data are available regarding the use of vaginal the following conditions:
estradiol for UTI prophylaxis in postmenopausal women.
• Pregnancy. See pregnancy section.
Acute Uncomplicated Pyelonephritis • Before invasive procedures. Post-operative
complications, including bacteremia, are reduced are
Patients presenting with typical lower tract symptoms decreased by treating bacteriuria prior to urologic
(dysuria, frequency, urgency, etc.) with associated flank procedures.
pain, abdominal pain, nausea, vomiting, fever or chills • Renal transplant recipients.
should be suspected of having pyelonephritis. In fact, a
significant percentage (up to 20% in some cases) of patients • Children.
who present with seemingly uncomplicated UTI without Treatment of asymptomatic bacteriuria in women with
typical pyelonephritis symptoms can be shown by diabetes does not reduce complications, and therefore
bacteriologic localization studies to have involvement of diabetes is not an indication for screening or treatment of
the kidney. Many women with pyelonephritis can be safely asymptomatic bacteriuria.
managed on an outpatient basis with oral antibiotics.
Hospital admission with intravenous antibiotics is indicated UTI in Pregnancy
for acutely toxic patients, pregnant or immunocompromised
women, women unable to take in oral fluids, or in those UTI is the most frequent medical complication of
where compliance is a significant issue. pregnancy. Physiologic changes, both hormonal and
mechanical, predispose the bacteriuric woman to an
6 UMHS Urinary Tract Infection Guideline, May 2005
increased risk for developing acute pyelonephritis, preterm
birth, and unexplained perinatal death. Factors contributing Information the Patient Needs to Know
to increased risk of disease include dilation of the ureters
and renal pelvises, increased urinary pH, and glycosuria • Cause. UTI are caused by bacteria and require
promoting bacterial growth and decrease in the ureteric antibiotic treatment.
muscle tone.
• Complete treatment. Antibiotic must be taken for the
Asymptomatic bacteria (ASB). ASB occurs in 4-7% of full prescribed duration, even if symptoms disappear.
pregnant patients. Unlike nonpregnant women with ASB,
in whom intervention is not recommended, pregnant • Fluids. You should drink at least 8 glasses of fluids
patients with ASB will go on to develop pyelonephritis in per day to help flush the urinary system.
up to 40% of cases if left untreated. Pyelonephritis in the
pregnant patient leads to septicemia in 10-20% of cases and • Possible side effects of treatment. Side effects of
ARDS in 2%. Screening for asymptomatic bacteriuria is antibiotics include rash, nausea, diarrhea, vaginitis. If
recommended for pregnant women at the first prenatal visit. your doctor prescribes a urinary analgesic,
Urine culture is an appropriate screening tool. Clean catch phenazopyridine (Pyridium), to help with pain, it may
urine analysis is recognized as an appropriate screening turn your urine an orange color.
tool by the American College of Obstetricians and
Gynecologists.
• Call for early follow-up. Symptoms that require early
follow-up included: persistent fever or discomfort
Treatment of ASB can be accomplished with a variety of
persisting greater than 72 hours after starting therapy,
FDA category B drugs (see definitions below) including
inability to take antibiotic due to nausea or vomiting,
amoxicillin, cephalosporins, nitrofurantoin and
development of any new symptoms.
trimethoprim/sulfa. Quinolones should generally not be
used during pregnancy (FDA Category C). A seven day
• Call if symptoms return. If your symptoms of
course is recommended with follow-up urine cultures to
urinary tract infection return after completing your
document sterile urine. Persistent bacteruria requires re-
antibiotic, you should contact your physician.
treatment guided by sensitivities and then consideration of
suppressive therapy, usually with nitrofurantoin.
Patient education information about UTI is available to
provide more detail and reinforce instruction.
FDA pregnancy risk categories for drugs are:
• Category A = Controlled studies in women fail to
demonstrate a risk to the fetus in the first trimester (and
there is no evidence of a risk in later trimesters), and Strategy for Literature Search
the possibility of fetal harm appears remote. The drug
should be used during pregnancy only if clearly needed The literature search for this update began with the results
• Category B = Animal-reproduction studies have not of the literature search performed for the earlier version of
demonstrated a fetal risk but there are no controlled this guideline. A search for literature published since that
studies in pregnant women OR animal reproduction time was performed. The search was conducted
studies have shown an adverse effect that was not prospectively using the major keywords of: urinary tract
confirmed in controlled studies in women in the first infections (including bacteriuria, pyuria, or schistosomiasis
trimester. The drug should be used in pregnancy only haematobia), guidelines, controlled trials, published from
if clearly indicated 7/1/98 to 8/31/04 years, adult women on Medline. Specific
searches were performed for: predictive value of tests,
• Category C = Studies in animals have revealed adverse
diagnosis (other than predictive value of tests), treatment,
effects on the fetus and there are no controlled studies
uncomplicated UTI – treatment, pregnancy,
in women OR studies in women and animals are not
postmenopausal women – treatment, recurrent UTI, self
available. The drug should be used only if the
initiated therapy, group B strep and non-pregnant women,
potential benefit justifies the potential risk
telephone triage – nursing protocol, other treatment, other
• Category D = There is evidence of human fetal risk,
references to UTI.
but the benefits from use in pregnant women may be
acceptable despite the risk (e.g., if the drug is needed
The search was conducted in components each keyed to a
in a life-threatening situation or for a serious disease
specific causal link in a formal problem structure (available
for which safer drugs cannot be used or are
upon request). The search was supplemented with recent
ineffective).
clinical trials known to expert members of the panel.
Negative trials were specifically sought. The search was a
Symptomatic cystitis in pregnancy. Symptomatic
single cycle. Conclusions were based on prospective
cystitis, in pregnancy, although rare, should be treated and
randomized clinical trials if available, to the exclusion of
followed-up similarly to ASB. Acute pyelonephritis, which
other data; if RCTs were not available, observational
occurs in 1-2% of all pregnancies, should be treated with
studies were admitted to consideration. If no such data
hospitalization and IV antibiotics.
7 UMHS Urinary Tract Infection Guideline, May 2005
were available for a given link in the problem formulation, three day or greater than five day courses of therapy.
expert opinion was used to estimate effect size. Single dose therapy was less effective than 3-day or >5,
trimethoprim/sulfa was felt to be optimum therapy and
there was no increased benefit from extending therapy to
Disclosures >5 days. β lactams, however, were effective when
treatment was extended past 5 days.
The University of Michigan Health System endorses the
Guidelines of the Association of American Medical Saint, S., Scholes, D., Fihn, S.D., Farrell, R.G., and Stamm,
Colleges and the Standards of the Accreditation Council for W.E. The effectiveness of a clinical practice guideline for
Continuing Medical Education that the individuals who the management of presumed uncomplicated urinary tract
present educational activities disclose significant infection in women. The American Journal of Medicine,
relationships with commercial companies whose products 1999; 106:638-641.
or services are discussed. Disclosure of a relationship is Before-and-after study with concurrent control groups at
not intended to suggest bias in the information presented, 24 primary care clinics to assess the effect of a
but is made to provide readers with information that might telephone-based clinical practice guideline for managing
be of potential importance to their evaluation of the presumed cystitis. Women 18 to 55 who met specific
information. criteria were managed without a clinical visit or
laboratory testing. Guideline use decreased laboratory
Team Member Company Relationship utilization and overall costs while maintaining or
Carol E. Chenoweth, MD (None) improving the quality of care.
Karen R. Fonde, MD (None)
Steven E. Gradwohl, MD (None) Schultz, H.J. et. al. Acute cystitis: A prospective study of
R. Van Harrison, PhD (None) laboratory tests and duration of therapy. Mayo Clinic Proc.
Lauren B. Zoschnick, MD (None) 1984; 59: 391-397.
Prospective trial which showed none of the routine
pretreatment tests (Urinalysis, UC, sensitivities) or
Acknowledgments follow-up tests were predicative of outcome. Most
women (>90%) responded to empiric therapy with
In addition to current team members on the front page, the trimethoprim/sulfa.
following individual is acknowledged for her contributions
to the 1999 version of this guideline: Kathy Munger, MS, Gupta, K., et. al. Patient-initiated treatment of
BSN, RN, Ambulatory Care Nursing. uncomplicated recurrent urinary tract infections in young
women. Ann Intern Med. 2001; 135: 9-16.
Women with previous UTI were able to accurately self-
Annotated References diagnose and treat recurrent episodes of UIT. Clinical
cure rates of 92%, microbiological cure rate of 96%.
Cochrane Systematic Review, Antibiotics for preventing
recurrent urinary tract infection in non-pregnant women, Gupta, K., Hooten, T., Stamm, W. Increasing antimicrobial
Volume 3 2004 resistance and management of uncomplicated community-
acquired urinary tract infections. Ann Intern Med.
Patient-initiated treatment of recurrent urinary tract 2001;135:41-50.
infection in women. Annals of internal medicine 2001: 135
[1]:9-16 Reviews rationale for empirical antimicrobial therapy for
uncomplicated UTI based on local antimicrobial
Hooton, T.M. et.al. Randomized comparative trial and cost susceptibilities.
analysis of 3-day antimicrobial regimens for treatment of
acute cystitis in women. JAMA. 1995; 273(1): 41-45. Miller, L.G., et. al. Treatment of uncomplicated urinary
tract infections in an era of increasing antimicrobial
Prospective randomized trial comparing the outcome of resistance. Mayo Clin Proc. 2004:79(8):1048-54.
3-day regimens of trimethoprim, sulfa, nitrofurantoin,
cefadroxil and amoxicillin in women with cystitis. Excellent concise review.
Trimethoprim/sulfa was shown to be more effective 80%
(vs. < 67%) and less expensive than the other regimens. Warren, J, Abrutyn J, Hebel R, etal. Guidelines for
antimicrobial treatment of uncomplicated acute bacterial
Norrby, S.R. Short-term treatment of uncomplicated lower cystitis and acute pyelonephritis in women. Clin Infect Dis.
urinary tract infections in women. Reviews of Infectious 1999;29:745-58.
Diseases. 1990; 12: 458-467. Treatment guidelines endorsed by IDSA, American
Review of 28 trials on women with uncomplicated Urologic Association, the European Society of clinical
urinary tract infection comparing single dose therapy to Microbiology and Infectious Diseases.