Philippine Clinical Practice

Guidelines on the Diagnosis and

Management of Urinary Tract
Infections in Adults
2014 Update

Asymptomatic Bacteriuria and

Recurrent Urinary Tract Infection

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Asymptomatic Bacteriuria in Adults - Screening and Treatment

Definition

¾¾ For asymptomatic women, bacteriuria is defined as two consecutive

voided urine specimens with isolation of the same bacterial strain in
quantitative counts ≥ 100,000 cfu/mL.
Strong recommendation, High quality of evidence

¾¾ In men, a single, clean-catch voided urine specimen with one bacterial
species isolated in a quantitative count ≥100,000 cfu/mL identifies
bacteriuria.
Strong recommendation, High quality of evidence
¾¾ In both men and women, a single catheterized urine specimen with
one bacterial species isolated in a quantitative count ≥ 100 cfu/mL
identifiesbacteriuria.
Strong recommendation, High quality of evidence

• All diagnosis of asymptomatic bacteriuria should be based on results

of urine culture specimens that are collected aseptically and with no
evidence of contamination.
Strong recommendation, High quality of evidence

Indications for screening and treatment:

¾¾ Screening and treatment for asymptomatic bacteriuria is

recommended in the following:
(a) All pregnant women.
Strong recommendation, High quality of evidence

(b) Patients who will undergo genitourinary manipulation or

instrumentation.
Strong recommendation, High quality of evidence

Cases where screening and treatment for asymptomatic bacteriuria is NOT

indicated

¾¾ Routine screening and treatment for asymptomatic bacteriuria is not

recommended for healthy adults.
Strong recommendation, Low quality of evidence

¾¾ Likewise, periodic screening and treatment for asymptomatic

bacteriuria is not recommended in the following:

(a) Patients with diabetes mellitus

Strong recommendation, Moderate quality of evidence
(b) Elderly patients
Strong recommendation, High quality of evidence
 (c) Patients with indwelling catheters
Weak recommendation, Low quality of evidence

Except in the following special populations

(1) Pregnant patients
Strong recommendation, Moderate quality of evidence
(2) Those who will undergo urologic procedures
Strong recommendation, Moderate quality of evidence
(3) Those whose bacterial agents cause high incidence of
bacteremia in their institution
Weak recommendation, Low quality of evidence
(4) Neutropenic patients
Weak recommendation, Low quality of evidence
(5) Those that may be part of an infection control plan to
manage cluster infections in a unit
Weak recommendation, Low quality of evidence

(d) Solid organ transplant patients, unless an indwelling catheter is present

Weak recommendation, Low quality of evidence
(e) HIV patients
Weak recommendation, Low quality of evidence
(f) Spinal cord injury patients
Strong recommendation, Low quality of evidence
(g) Patients with urologic abnormalities
Weak recommendation, Low quality of evidence

Screening tests

¾¾ Screening by urine culture is recommended.

Strong recommendation, High quality of evidence

¾¾ In the absence of facilities for urine culture, significant pyuria (>10

wbc/hpf) or a positive gram stain of unspun urine (>2 microorganisms/
oif) in two consecutive midstream urine samples can be used to
screen for asymptomatic bacteriuria.
Strong recommendation, Low quality of evidence

¾¾ Urine culture and sensitivity testing are not necessary when urinalysis
is negative for pyuria or urine gram stain is negative for organisms.
Strong recommendation, Moderate quality of evidence

¾¾ Pyuria accompanying asymptomatic bacteriuria is not an indication

for antimicrobial treatment among patients for whom screening and
treatment is not recommended.
Strong recommendation, Low quality of evidence
 Treatment of Asymptomatic Bacteriuria

¾¾ The choice of antibiotic depends on culture results. A seven-day

regimen is recommended.
Strong recommendation, Low quality of evidence

¾¾ For specific recommendations on pregnant women, refer to Table 1

and the section on UTI in Pregnancy.

Table 1. Antibiotics that can be used for asymptomatic

Table 1. Antibiotics
bacteriuria that can be used for asymptomatic bacteriuria in
in pregnancy
pregnancy
Antibiotics Recommended dose FDA Risk Category
and duration
Cephalexin 500 mg BID for 7 days B
Cefuroxime axetil 500 mg BID for 7 days B

Fosfomycin 3 g single dose B

trometamol
Amoxicillin- 625 mg BID for 7 days B
clavulanate
Nitrofurantoin 100 mg QID for 7 B
macrocrystal days;100 mg BID for 7
days for monohydrate May cause hemolytic
macrocrystal anemia, nophthalmia,
formulation hypoplastic left heart
syndrome, ASD, cleft lip
(not available locally) and palate.

May be given on the

second trimester of
pregnancy until 32
weeks AOG.

Use in the first

trimester of pregnancy
is appropriate when
no other suitable
alternative antibiotics
are available)

Trimethoprim- 160/800 mg BID for 7 C (avoid in 1st and 3rd

sulfamethoxazole days trimester)
Algorithm 1: Screening and Treatment of Asympomatic Bacteriuria

Patient with NO signs or symptoms

of urinary tract infection

Is the patient…
NO
 Pregnant? No need for
 About to undergo screening and
genitourinary manipulation/ treatment
instrumentation?

YES
NEGATIVE
Screen for ASB No need for treatment
with urine culture

POSITIVE

Treat based on culture

results
a

Recurrent UTI - Diagnosis

Definition
 Recurrent UTI - Diagnosis

Definition

¾¾ Recurrent UTI is diagnosed when a healthy non-pregnant woman

with no known urinary tract abnormalities has 3 or more episodes of
acute uncomplicated cystitis documented by urine culture during a
12-month period OR 2 or more episodes in a 6-month period.

¾¾ Recurrent UTI may either be a relapse or a reinfection.

o Relapse occurs when the initial organism persists within the

urinary tract and re-emerges despite adequate treatment usually
occurring 1-2 weeks after stopping treatment.

o Reinfection occurs when recurrent UTI is caused by a different

bacterial isolate, or by the previously isolated bacteria after a
negative intervening culture or an adequate period (≥ 2 weeks)
between infections.

Screening

¾¾ Routine screening for urologic abnormalities is not recommended for

the general patient population.
Strong recommendation, Low quality of evidence

¾¾ Screening for urologic abnormalities is recommended in the following

situations:

(a) No response to appropriate antimicrobial therapy or rapid

relapse after such therapy
(b) Gross hematuria during a UTI episode or persistent microscopic
hematuria
(c) Obstructive symptoms
(d) Clinical impression of persistent infection
(e) Infection with urea-splitting bacteria (Proteus, Morganella,
Providencia)
(f) History of pyelonephritis
(g) History of or symptoms suggestive of urolithiasis
(h) History of childhood UTI
(i) Elevated serum creatinine
Diagnostics

¾¾ Radiologic or imaging studies and cystoscopy are not routinely

indicated in patients with recurrent UTI.
Weak recommendation, Low quality of evidence

¾¾ Renal ultrasound or CT scan/stonogram may be done to screen for

urologic abnormalities
Strong recommendation, Low quality of evidence

¾¾ Patients with anatomical abnormalities should be referred to a

specialist (nephrologist or urologist) for further evaluation.
Strong recommendation, Low quality of evidence
 Recurrent UTI - Prevention

Prophylaxis

¾¾ Prophylaxis is recommended in women whose frequency of

recurrence is not acceptable to the patient in terms of level of
discomfort or interference with activities of daily living.
¾¾ Prophylaxis may be withheld according to patient preference if the
frequency of recurrence is tolerable to the patient.
Strong recommendation, Low quality of evidence

¾¾ The following factors should guide the physician in determining

the patient’s risk-benefit profile and in deciding which prophylactic
strategies will be used:
(a) Frequency and pattern of recurrences

(b) Patient’s lifestyle, compliance and willingness to commit to a

specific regimen
(c) Plans for a pregnancy
(d) Antimicrobial resistance and susceptibility pattern of the
organisms causing the patient’s previous UTI
(e) Risk of adverse events and drug allergies

Antibiotic prophylaxis

¾¾ Antibiotic prophylaxis should only be initiated after counseling and

behavior modification have been attempted in order to minimize
antibiotic exposure and possible adverse effects.
Strong recommendation, Low quality of evidence

¾¾ Antibiotic prophylaxis should be limited to women with recurrent UTI

in whom non-antimicrobial strategies have not been effective and
who prefer prophylactic antimicrobial therapy.
Strong recommendation, Moderate quality of evidence

¾¾ If a decision is made to give antibiotic prophylaxis, any of the following

is recommended:

(a) Continuous prophylaxis, defined as the daily intake of a low-

dose of antibiotic for 6-12 months
Strong recommendation, Moderate quality of evidence
(b) Post-coital prophylaxis, defined as the intake of a single dose
of antibiotic immediately after sexual intercourse
Strong recommendation, Moderate quality of evidence
(c) Intermittent prophylaxis, defined as self-treatment with a
single antibiotic dose based on patient’s perceived need.
Weak recommendation, Low quality of evidence
• Any of the antibiotics in Table 2 given either continuously for 6 to
12 months or as post-coital prophylaxis can reduce the clinical and
microbiologic recurrence of UTI episodes.
Strong recommendation, Moderate quality of evidence

Table 2. Antibiotics proven effective in reducing the number

of recurrences of UTI
Antibiotics Recommended doses
Continuous Post-coital Intermittent
prophylaxis prophylaxis prophylaxis
Nitrofurantoin 50-100 mg at 50-100 mg 50 mg
bedtime

Trimethoprim 100 mg at 100 mg

bedtime

Trimethoprim - 40 mg/200 mg 40 mg/200 mg 40 mg/200 mg

sulfamethoxazole at bedtime

Trimethoprim - 40 mg/200 mg 80 mg/400 mg

sulfamethoxazole 3x/week

Ciprofloxacin 125 mg at 125 mg 125 mg

bedtime
Norfloxacin 200 mg at 200 mg 200 mg
bedtime
Ofloxacin 100 mg
Pefloxacin 400 mg weekly

Cefalexin 125-250 mg at 125-250 mg

bedtime

Cefaclor 250 mg at 250 mg

bedtime
Fosfomycin 3 g every 10
days
Amoxicillin 500 mg
Cefuroxime 250 mg
 Recurrent UTI - Prevention

Methenamine salts

• Methenamine hippurate may be used as an alternative to antibiotics

for short-term prophylaxis (one week) to prevent UTI in patients
without urinary tract abnormalities.
Weak recommendation, Low quality of evidence
Behavioral measures to prevent recurrent UTI

¾¾ Behavioral measures can be useful antimicrobial-sparing measures

in the prevention of recurrent UTI.
Weak recommendation, Low quality of evidence

¾¾ These behavioral measures include the following:

(a) Post-defecation and anal cleansing antero-posteriorly in women

to avoid contaminating the periurethral area with fecal flora
(b) Post-coital douche or post-coital urination
(c) Liberal fluid intake especially after intercourse

(d) Avoidance of tight-fitting underwear

(e) Use of alternative form of contraception for women using
spermicide-containing contraceptives

Biologic mediators

A. Lactobacilli

 Lactobacilli both in oral form and vaginal suppositories are not

recommended in the prevention of UTI.
Strong recommendation, High quality of evidence

B. Cranberry products

 Cranberry juice and cranberry products can be used among

patients wherein long-term antibiotic prophylaxis for recurrent
UTI is deemed necessary to avoid emergence of resistance of
fecal and urine isolates of E. coli to trimethoprim, amoxicillin and
ciprofloxacin.

 The recommended dose for UTI prevention is daily consumption

of 300 mL of cranberry juice cocktail or 500 mg capsules
containing 36 mg PACs) taken twice a day as the anti-adhesion
activity decreases over time.
 Strong recommendation, Moderate quality of evidence

Table 3. Available cranberry products in the Philippines

Cranberry Components PAC component Price per

Products bottle
Cranbiotics Cranberry 120 mg P615/60 caps
extract (standardized for
(Futurebiotics) 30% PACs)
Lactobacillus
sporogenes

CranRx Cranberry 500 mg (3X more P400/30 caps

(Natures way) extract Standardized
PACs)
Cranberry Cranberry 5,600 mg (700 mg P410/90 caps
concentrate concentrate - 8:1 extract) whole
cranberries
(NOW foods) Vitamin C
Sugar
Cranberry Cranberry 500 mg P1,160
GNC Fruit Powder

Fontana Cranberry NS P84/1L

cranberry juice Vitamin C

Hormonal interventions for post-menopausal women

 Application of intravaginal estriol cream once each night for

2 weeks followed by twice-weekly applications for at least 8
months OR use of an estradiol-releasing silicone vaginal ring for
3 months is recommended for the prevention of recurrent UTI in
post-menopausal women
Strong recommendation, Moderate quality of evidence

 However, evidence is insufficient to recommend vaginal

estrogens over antibiotics for the prevention of recurrent UTI.

 Low-dose oral estrogen is not recommended for the prevention

of recurrent UTI. Oral estrogens were associated with coronary
heart disease, venous thromboembolism, stroke and breast
cancer.
 Recurrent UTI - Prevention

Strong recommendation, High quality of evidence

Immunoprophylaxis

 Immunoprophylaxis, using immune-active E. coli fractions

(Urovaxom), is recommended for the prevention of recurrent
UTI. The dosing regimen is once daily PO for 3 months.
Strong recommendation, Moderate quality of evidence

 A longer/extended dosing regimen (once daily for 3 months, rest

for 3 months, 10 days per month for 3 months, and rest for 3
months) may be associated with a better control of recurrence
in the longer term.
Weak recommendation, Moderate quality of evidence

Acupuncture

 Acupuncture on the lower abdomen, back or lower extremities

may be used as an alternative for prevention of recurrent UTI
among women when antibiotic prophylaxis is contraindicated.
Strong recommendation, Moderate quality of evidence

Oral hydration

 Oral water hydration (2 to 2.5 L/day) may be done to prevent

UTI.
 Recurrent UTI - Treatment

Weak recommendation, Low quality of evidence

 Consider intermittent self-administered therapy in highly

educated, well-informed, motivated patients, wherein the
patients are able to recognize the characteristic signs and
symptoms of UTI, are compliant with medical instructions and
have a good relationship with a medical provider.
Strong recommendation, Moderate quality of evidence

 Individual episodes of UTI in women with recurrent UTI or

breakthrough infections during prophylaxis can be treated
empirically with any of the antibiotics recommended for acute
uncomplicated cystitis (Table 4) other than the antibiotic being
given for prophylaxis. Always request for a urine culture and
modify the treatment accordingly.
Strong recommendation, Moderate quality of evidence

Non pharmacologic interventions

 Cranberry juice and cranberry products are not recommended

for the treatment of urinary tract infection.
Strong recommendation, Low quality of evidence

 There is no available evidence to recommend coconut juice in

the prevention or treatment of UTI.

Table 4. Antibiotics for acute uncomplicated cystitis

Antibiotics Recommended dose

and duration
Primary Nitrofurantoin monohydrate 100 mg BID for 5 days PO
macrocrystals (not sold
locally)
Nitrofurantoin macrocrystals 100 mg QID for 5 days PO
Fosfomycin trometamol 3 g single dose PO
Alternative Pivmecillinam 400 mg BID for 3–7 days PO
(not sold locally)
Ofloxacin 200 mg BID for 3 days PO
Ciprofloxacin 250 mg BID for 3 days PO
Ciprofloxacin extended 500 mg OD for 3 days PO
release
Levofloxacin 250 mg OD for 3 days PO
Norfloxacin 400 mg BID for 3 days PO
Amoxicillin clavulanate 625 mg BID for 7 days PO
Cefuroxime axetil 250 mg BID for 7 days PO
Cefaclor 500 mg TID for 7 days PO
Cefixime 200 mg BID for 7 days PO
Cefpodoxime proxetil 100 mg BID for 7 days PO
Ceftibuten 200 mg BID for 7 days PO
 ONLY Trimethoprim- 160/800 mg BID for 3
if with sulfamethoxazole (TMP-SMX) days PO
proven
susceptibility

Table 5. Strength of recommendation and Quality of Evidence

Category/Grade Definition
Strength of Recommendation
Strong Clear desirable or undesirable effects
Weak Desirable and undesirable effects closely
balanced or uncertain
Quality of Evidence
High Consistent evidence from well-performed RCTs
or exceptionally strong evidence from unbiased
observational studies
Moderate Evidence from RCTs with important limitations
or moderately strong evidence from unbiased
observational studies
Low Evidence from ≥ one critical outcome from
observational studies, from RCTs with serious
flaws or from indirect evidence
Very Low Evidence for ≥ one critical outcome from
unsystematic clinical observation or very indirect
evidence

Sources:
Task Force on Urinary Tract Infections, Philippine Practice Guideline
Group Infectious Disease. Philippine Clinical Practice Guidelines on
the Diagnosis and Management of Urinary Tract Infections in Adults
2013 Update. Quezon City, Philippines: PPGG-ID Philippine Society for
Microbiology and Infectious Disease; 2013

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello

P, Schunemann HJ, GRADE Working Group. GRADE: an emerging
consensus on rating quality of evidence and strength of recommendations.
BMJ 2008; 336: 924-926

Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A,

Schünemann HJ and for the GRADE Working Group. Going from
evidence to recommendations. BMJ 2008; 336: 1049-51

UTI Task Force

Chair: Mediadora C. Saniel, MD

Co Chair: Marissa M. Alejandria, MD

ASB in Adults Cluster

Ricardo M. Manalastas Jr., MD (Head)

Louella P. Aquino, MD
Shahreza L. Baquiran, MD
Sybil Lizzane R. Bravo, MD
Jennifer Co, MD
Maria Meden P. Cortero, MD
Lorina Q. Esteban, MD
Analyn F. Fallarme, MD
May Gabaldon, MD
Jill R. Itable, MD
Alfredo M. Lopez, Jr, MD
Helen V. Madamba, MD
Josefa Dawn V. Martin, MD
Erwin R. de Mesa, MD
Sharon Faith B. Pagunsan, MD
Oliver S. Sanchez, MD
Katha W. Ngo-Sanchez, MD

Recurrent UTI Cluster

Marissa M. Alejandria, MD
Coralie Therese Dimacali, MD
Leilanie Apostol-Nicodemus, MD
Maria Carmela Lapitan, MD
Rommel Bataclan, MD
Tennille Tan, MD
Mark Brian Tan, MD