Clinical practice guidelines for the antibiotic treatment of community-acquired urinary tract infections

Key points

• This update of the 2011 Korean guideline covers community-acquired urinary tract infections (UTIs) in adults; healthcare-associated and catheter-associated UTIs and infections in immunocompromised patients are excluded.
• Asymptomatic bacteriuria should be screened for and treated in pregnant women in early gestation (strong, low evidence) and before urological procedures with expected mucosal bleeding such as TUR-P (strong, high evidence), but not in non-pregnant women, nursing home residents, diabetic women, spinal cord injury or indwelling catheters.
• For acute uncomplicated cystitis in outpatients, nitrofurantoin 100 mg twice daily for more than 5 days or a single 3 g dose of fosfomycin trometamol is recommended (strong, high evidence).
• All patients with acute pyelonephritis should have a urine culture before empirical antibiotics, and treatment should be adjusted to susceptibility results (strong, very low evidence).
• Acute bacterial prostatitis needs immediate inpatient care and intravenous antibiotics after urine and blood cultures; third-generation cephalosporins, a broad-spectrum beta-lactam/beta-lactamase inhibitor or a carbapenem are recommended (strong, low evidence).

Overview

This guideline from Korean infectious disease, chemotherapy, urology and nephrology societies gives recommendations for asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, complicated pyelonephritis related to urinary tract obstruction and acute bacterial prostatitis. Causative bacteria in Korea are more resistant to TMP/SMX than in the United States and Europe, and fluoroquinolones are mainly recommended there as primary antibiotics, while nitrofurantoin and fosfomycin can be used for lower UTIs only. Evidence levels were converted to GRADE criteria. This overview is based on the abstract and the recommendation statements; some statements were only partly read.

Urine culture

A urine culture should be performed in patients suspected of pyelonephritis, with atypical symptoms, in pregnancy, in men suspected of UTI, and when symptoms do not improve within 2-4 weeks after treatment or recur (strong, low evidence).

Pyelonephritis and urinary obstruction

Against susceptible ESBL-producing bacteria, fosfomycin, TMP/SMX, cefepime, ceftazidime-avibactam, ceftolozane-tazobactam, amoxicillin-clavulanate, piperacillin-tazobactam or amikacin may be used instead of carbapenems (weak, low evidence). Pyelonephritis related to obstruction requires decompression in addition to antibiotics (strong, high evidence), with drainage as soon as possible when needed; empirical therapy follows the uncomplicated pyelonephritis protocol, or the sepsis protocol if symptoms are severe. If the obstruction is corrected and there are no other infection factors, antibiotics may be given for 7-14 days, extended to over 21 days if the response is insufficient. In emphysematous pyelonephritis with invasion of the kidney parenchyma, percutaneous drainage or surgery is added to antibiotics.

Acute bacterial prostatitis

Patients should be hydrated and rested, with NSAIDs if needed, and empirical antibiotics continued until susceptibility results are available. Alpha-blockers are recommended if there is residual urine or urinary symptoms (strong, low evidence). A suprapubic catheter should be maintained in acute urinary obstruction, while urethral catheterization without obstruction may increase the risk of chronic prostatitis. Prostatic abscesses not responding to antibiotics may be drained by ultrasound-guided aspiration or catheter drainage, or by transurethral resection.

FAQ

Who should be treated for asymptomatic bacteriuria?

Pregnant women and patients before urological procedures with expected mucosal bleeding; screening and treatment are not recommended in non-pregnant women, nursing home residents, diabetic women, patients with spinal cord injury or with indwelling catheters.

What are the first-line options for uncomplicated cystitis?

Nitrofurantoin 100 mg twice daily for more than 5 days or fosfomycin trometamol 3 g as a single dose.

How long is treatment for pyelonephritis with urinary obstruction?

7-14 days if the obstruction is corrected and there are no other infection factors, extended to over 21 days if the response is insufficient.

Source

Kang CI, Kim J, Park DW, et al. Clinical Practice Guidelines for the Antibiotic Treatment of Community-Acquired Urinary Tract Infections. Infect Chemother 2018;50(1):67-100. DOI: 10.3947/ic.2018.50.1.67. Open access under CC BY-NC 3.0. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.