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PRACTICE
BULLETIN
CLINICAL MANAGEMENT GUIDELINES FOR
OBSTETRICIAN–GYNECOLOGISTS
NUMBER 91, MARCH 2008
Treatment of Urinary
This Practice Bulletin was Tract Infections in
developed by the ACOG Com-
mittee on Practice Bulletins— Nonpregnant Women
Gynecology with the assistance
An estimated 11% of U.S. women report at least one physician-diagnosed uri-
of Jeanne Sheffield, MD. The
nary tract infection (UTI) per year, and the lifetime probability that a woman
information is designed to aid
will have a UTI is 60% (1, 2). Despite the frequency of UTIs, there is confusion
practitioners in making deci-
about diagnostic strategies, and changes in antimicrobial resistance among
sions about appropriate obstet-
uropathogens require alterations in traditional treatment regimens. The pur-
ric and gynecologic care. These
guidelines should not be con- pose of this bulletin is to address the diagnosis, treatment, and prevention of
strued as dictating an exclusive uncomplicated acute bacterial cystitis and acute bacterial pyelonephritis in
course of treatment or proce- nonpregnant women. Complicated UTIs (eg, in patients with diabetes mellitus,
dure. Variations in practice may abnormal anatomy, prior urologic surgery, a history of renal stones, an indwelling
be warranted based on the catheter, spinal cord injury, immunocompromise, or in pregnant patients) are a
needs of the individual patient, heterogeneous group of conditions beyond the scope of this bulletin.
resources, and limitations
unique to the institution or type
of practice. Background
Reaffirmed 2016 Definitions
Urinary tract infections are among the most common bacterial infections in adults
and may involve the lower or upper urinary tract or both. Asymptomatic bacteri-
uria refers to considerable bacteriuria in a woman with no symptoms. When the
infection is limited to the lower urinary tract and occurs with symptoms of dysuria
and frequent and urgent urination and, occasionally, suprapubic tenderness, it is
termed cystitis. Acute pyelonephritis is defined as infection of the renal paren-
chyma and pelvicaliceal system accompanied by significant bacteriuria, usually
occurring with fever and flank pain. Recurrent UTI with the same organism after
adequate therapy is termed a relapse. Reinfection is a recurrent UTI caused by bac-
teria previously isolated after treatment and a negative intervening urine culture
result or a recurrent UTI caused by a second isolate.
Prevalence and Epidemiology frequently are associated with structural abnormalities of
the urinary tract, indwelling catheters, and renal calculi
The burden from UTIs on both the clinical and financial
(5, 6). Enterococcus species also have been isolated in
aspects of health care in the United State is immense.
women with structural abnormalities. Gram-positive iso-
Approximately 62.7 million adults aged 20 years and
lates, including group B streptococci, are increasingly
older have reported at least one episode of a UTI or cys-
isolated along with fungal infections in women with
titis (3), 50.8 million (81%) of whom were women. In
indwelling catheters (6). Anaerobic organisms and
2000, there were an estimated 11 million office and out-
mycoplasmas are uncommonly isolated from UTIs and
patient hospital visits by patients aged 20 years and older
probably have a minor role in urinary tract pathogenesis.
with a UTI (approximately 9 million visits by women).
The cost to the health care system in 2000 was estimated Although ascending infection is the predominant
to be 3.5 billion dollars for evaluation and treatment route of infection in the urinary tract, occasionally infec-
(2, 3). More than one half of women will have at least tion may arise from hematogenous or lymphatic spread.
one UTI during their lifetime (1), and 3–5% of all Bloodborne pathogens may seed the renal parenchyma
women will have multiple recurrences (4). The preva- during episodes of bacteremia. Renal abscesses may arise
lence of asymptomatic bacteriuria also is higher in from bacterial endocarditis bacteremia from Staphylo-
women than men; 5–6 % in young, sexually active, non- coccus aureus. Rare cases of pyelonephritis, caused by
pregnant women, compared with less than 0.1% in fungemia from Candida species in hospitalized patients,
young men. The prevalence increases to 20% in women have been reported. Although lymphatic connections are
older than 65 years (5). present along the ureters and kidneys and reverse lym-
phatic flow into the kidneys has been reported, lymphatic
Pathophysiology and Microbiology spread of microorganisms leading to UTI is rare (8).
Urinary tract infections result from interactions between
Risk Factors
host biologic and behavioral factors and microorganism
virulence. Most cases are caused by ascending infection Risk factors for UTI in women vary among the different
from the urethra into the bladder. The female urethra is age groups. In school-aged girls, common risk factors
short, and the external one third is often colonized by include congenital abnormalities and new onset of sex-
pathogens from normal vaginal and enteric flora. ual activity. Risk factors for premenopausal and post-
Bacteria travel up the urethra during urethral massage, menopausal women are listed in the box. With advancing
sexual intercourse, or mechanical instrumentation. Once age, the rate of UTI increases, likely because of the
in the bladder, bacterial factors play a major role in col- hypoestrogenic state and vaginal epithelium atrophy,
onization and infection. Although UTIs are caused by impaired voiding, and changes in hygiene (7, 9). A life-
many species of microorganisms, most (80–90%) are time history of UTIs also is an important predictor of
caused by uropathogenic Escherichia coli (predominantly UTIs in postmenopausal women (10).
O, K, and H antigen serotypes) (1, 4–6). These E coli
serogroups have a number of virulence factors that facil- Diagnosis
itate colonization and invasion of the vagina and urinary
tract. Specific virulence factors, such as Type 1 fimbria, Clinical History and Examination
P-fimbria, and S-fimbria, enhance binding to vaginal and Acute bacterial cystitis usually presents clinically as
uroepithelial cells. Virulence factors also increase resist- dysuria, with symptoms of frequent and urgent urination,
ance to serum bactericidal activity and resistance to host secondary to irritation of the urethral and bladder
phagocytic activity. Certain E coli subgroups also are mucosa. Women also may experience suprapubic pain or
associated with ascending infection into the renal pressure and rarely have hematuria. Fever is uncommon
parenchyma, causing pyelonephritis (predominantly in women with uncomplicated lower UTI. Acute urethri-
P-fimbriated E coli). tis secondary to infection from Neisseria gonorrhoeae
The remaining 10–20% of UTIs are caused by other and Chlamydia trachomatis or pain secondary to genital
microorganisms, occasionally colonizing the vagina and herpes simplex virus type 1 and herpes simplex virus
periurethral area (1, 4–6). Staphylococcus saprophyticus type 2 may occur with similar clinical symptoms and
frequently causes lower UTIs and has been isolated in should be ruled out.
3% of nonpregnant, sexually active, reproductive-aged In contrast, upper UTI or acute pyelonephritis fre-
women with pyelonephritis (7). Proteus, Pseudomonas, quently occurs with a combination of fever and chills,
Klebsiella, and Enterobacter species all have been iso- flank pain, and varying degrees of dysuria, urgency, and
lated in women with cystitis or pyelonephritis, and these frequency. Severe flank pain radiating to the groin is
although this management scheme is based on results years (1, 4). Management of recurrent UTIs should start
from few large treatment trials (14). In otherwise healthy with a search for known risk factors associated with
women who are clinically stable and able to tolerate oral recurrence. These include frequent intercourse, long-
antimicrobial agents and fluids, outpatient management is term spermicide use, diaphragm use, a new sexual part-
acceptable and has similar efficacy (14). The reliability of ner, young age at first UTI, and a maternal history of UTI
the patient and the social situation also should be taken (15, 16). Behavioral changes, such as using a different
into account when determining inpatient versus outpa- form of contraception instead of spermicide, should be
tient management. A urine culture is performed and advised. Antimicrobial treatment of recurrent UTIs is
empiric antibiotic therapy initiated as detailed in the next based on patient desire and frequency of recurrences. A
section. As in acute cystitis, β-lactams are not first-line 3-day course of one of the antimicrobial regimens listed
therapy in most cases. There is a high rate of ampicillin in Table 1 is started to clear the infection. A urine cul-
resistance in organisms causing pyelonephritis and a high ture test of cure 1–2 weeks later to confirm clearance is
rate of recurrence in those women treated with β-lactams. suggested.
The exception to this is if a gram-positive organism is the For women with frequent recurrences, continuous
causative agent. Amoxicillin or amoxicillin combined prophylaxis with once-daily treatment with nitrofurantoin,
with clavulanic acid may then be used. Regardless of norfloxacin, ciprofloxacin, trimethoprim, trimetho-
management scheme, 14 days of oral or parenteral antibi- prim–sulfamethoxazole, or another agent listed in Table 1
otics or both is now standard, with cure rates approaching has been shown to decrease the risk of recurrence by 95%
100%. Outcomes after a 2-week course are equivalent to (4). This can be continued for 6–12 months and then
the traditional 6-week parenteral course, with no differ- reassessed. Women with recurrences associated with sex-
ences in recurrence rates. A substantial clinical response ual activity may benefit from postcoital prophylaxis—a
should be evident by 48–72 hours after initiating therapy. single dose of one of the agents listed in Table 1, taken
A urine culture test of cure usually is performed when the after sexual intercourse, is effective in decreasing recur-
2-week course of antibiotics is completed. rences (1, 17, 18).
Proposed Performance 12. Hooton TM, Stamm WE. Diagnosis and treatment of
uncomplicated urinary tract infection. Infect Dis Clin
Measure North Am 1997;11:551–81. (Level III)
13. Gupta K, Scholes D, Stamm WE. Increasing prevalence of
The percentage of women in whom acute pyelonephritis antimicrobial resistance among uropathogens causing
is diagnosed who are treated with 14 days of antimicro- acute uncomplicated cystitis in women. JAMA 1999;
bial therapy 281:736–8. (Level II-3)
14. Warren JW, Abrutyn E, Hebel JR, Johnson JR, Schaeffer
AJ, Stamm WE. Guidelines for antimicrobial treatment of
References uncomplicated acute bacterial cystitis and acute
pyelonephritis in women. Infectious Diseases Society of
1. Fihn SD. Clinical practice. Acute uncomplicated urinary America (IDSA). Clin Infect Dis 1999;29:745–58. (Level
tract infection in women. N Engl J Med 2003;349: III)
259–66. (Level III) 15. Handley MA, Reingold AL, Shiboski S, Padian NS.
Incidence of acute urinary tract infection in young women
2. Griebling TL. Urinary tract infection in women. In:
and use of male condoms with and without nonoxynol-9
National Institute of Diabetes and Digestive and Kidney
spermicides. Epidemiology 2002;13:431–6. (Level II-2)
Diseases. Urologic diseases in America. NIH Publication
No. 07-5512. Washington, DC: Government Printing 16. Scholes D, Hooton TM, Roberts PL, Stapleton AE, Gupta
Office; 2007. p. 587–619. Available at: http://kidney. K, Stamm WE. Risk factors for recurrent urinary tract
niddk.nih.gov/statistics/uda/Urinary_Tract_Infection_in_ infection in young women. J Infect Dis 2000;182:
Women-Chapter18.pdf. Retrieved December 4, 2007. 1177–82. (Level II-2)
(Level III) 17. Melekos MD, Asbach HW, Gerharz E, Zarakovitis IE,
3. Griebling TL. Urinary tract infection in men. In: National Weingaertner K, Naber KG. Postintercourse versus daily
Institute of Diabetes and Digestive and Kidney Diseases. ciprofloxacin prophylaxis for recurrent urinary tract infec-
Urologic diseases in America. NIH Publication No. 07- tions in premenopausal women. J Urol 1997;157:935–9.
5512. Washington, DC: Government Printing Office; (Level II-2)
2007. p. 621–45. Available at: http://kidney.niddk.nih. 18. Pfau A, Sacks TG. Effective postcoital quinolone prophy-
gov/statistics/uda/Urinary_Tract_Infection_in_Men- laxis of recurrent urinary tract infections in women. J Urol
Chapter19.pdf. Retrieved December 4, 2007. (Level III) 1994;152:136–8. (Level II-1)
4. Hooton TM. Recurrent urinary tract infection in women. 19. Borrego F, Gleckman R. Principles of antibiotic prescrib-
Int J Antimicrob Agents 2001;17:259–68. (Level III) ing in the elderly. Drugs Aging 1997;11:7–18. (Level III)
5. Hooton TM, Stamm WE. The vaginal flora and urinary 20. Lutters M, Vogt-Ferrier NB. Antibiotic duration for treat-
tract infections. In: Mobley HL, Warren JW. Urinary tract ing uncomplicated, symptomatic lower urinary tract infec-
infections: molecular pathogenesis and clinical manage- tions in elderly women. Cochrane Database of Systematic
ment. Washington, DC: American Society for Microbiol- Reviews 2002, Issue 3. Art. No.: CD001535. DOI:
ogy Press; 1996. p. 67–94. (Level III) 10.1002/14651858.CD001535. (Level III)
31. Talan DA, Stamm WE, Hooton TM, Moran GJ, Burke T, 45. Raz R, Colodner R, Rohana Y, Battino S, Rottensterich E,
Iravani A, et al. Comparison of ciprofloxacin (7 days) and Wasser I, et al. Effectiveness of estriol-containing vaginal
pessaries and nitrofurantoin macrocrystal therapy in the
trimethoprim-sulfamethoxazole (14 days) for acute
prevention of recurrent urinary tract infection in post-
uncomplicated pyelonephritis in women: a randomized
menopausal women. Clin Infect Dis 2003;36:1362–8.
trial. JAMA 2000;283:1583–90. (Level I)
(Level II-2)
32. Norrby SR. Short-term treatment of uncomplicated lower
46. Raz R, Stamm WE. A controlled trial of intravaginal estriol
urinary tract infections in women. Rev Infect Dis
in postmenopausal women with recurrent urinary tract
1990;12:458–67. (Level III)
infections. N Engl J Med 1993;329:753–6. (Level I)
33. Leibovici L, Wysenbeek AJ. Single-dose antibiotic treat-
47. Kirkengen AL, Andersen P, Gjersoe E, Johannessen GR,
ment for symptomatic urinary tract infections in women: Johnsen N, Bodd E. Oestriol in the prophylactic treatment
a meta-analysis of randomized trials. Q J Med 1991;78: of recurrent urinary tract infections in postmenopausal
43–57. (Level III) women. Scand J Prim Health Care 1992;10:139–42.
34. Stein GE. Comparison of single-dose fosfomycin and a (Level I)
7-day course of nitrofurantoin in female patients with 48. Brown JS, Vittinghoff E, Kanaya AM, Agarwal SK,
uncomplicated urinary tract infection. Clin Ther 1999; Hulley S, Foxman B. Urinary tract infections in post-
21:1864–72. (Level I) menopausal women: effect of hormone therapy and risk
35. Richard GA, Mathew CP, Kirstein JM, Orchard D, Yang factors. Heart and Estrogen/Progestin Replacement Study
JY. Single-dose fluoroquinolone therapy of acute uncom- Research Group. Obstet Gynecol 2001;98:1045–52.
plicated urinary tract infection in women: results from a (Level I)