Warren JW, Abrutyn E, Hebel JR, et al.
Guidelines for antimicrobial treatment of uncomplicated acute bacterial
cystitis and acute pyelonephritis in women
Clin Infect Dis 1999; 29:745-58

This is part of the series of practice guidelines commissioned by the
Infectious Diseases Society of America (IDSA) through its Practice Guidelines
Committee. The purpose of this guideline is to provide assistance to
clinicians in the diagnosis and treatment of two specific types of urinary
tract infections (UTIs): uncomplicated, acute, symptomatic bacterial cystitis
and acute pyelonephritis in women. The guideline does not contain
recommendations for asymptomatic bacteriuria, complicated UTIs, Foley
catheter-associated infections, UTIs in men or children, or prostatitis. The
targeted providers are internists and family practitioners. The targeted
groups are immunocompetent women. Criteria are specified for determining
whether the inpatient or outpatient setting is appropriate for treatment.
Differences from other guidelines written on this topic include use of
laboratory criteria for diagnosis and approach to antimicrobial therapy. Panel
members represented experts in adult infectious diseases and urology. The
guidelines are evidence-based. A standard ranking system is used for the
strength of the recommendation and the quality of the evidence cited in the
literature reviewed. The document has been subjected to external review by
peer reviewers as well as by the Practice Guidelines Committee and was
approved by the IDSA Council, the sponsor and supporter of the guideline. The
American Urologic Association and the European Society of Clinical
Microbiology and Infectious Diseases have endorsed it. An executive summary
and tables highlight the major recommendations. Performance measures are
described to aid in monitoring compliance with the guideline. The guideline
will be listed on the IDSA home page at http://www.idsociety.org It will be
evaluated for updating in 2 years.


Executive Summary

   Objective: To develop evidence-based guidelines for antimicrobial treatment
of uncomplicated acute bacterial cystitis and acute pyelonephritis in women.
   Options: Many antimicrobial regimens comprising different drugs, doses,
schedules, and durations have been used to treat these common bacterial
infections. Only a few of these regimens have been directly compared in
adequately designed studies.
   Outcomes: We evaluated three end points for each regimen: frequency of
eradication of initial bacteriuria, recurrent bacteriuria, and adverse
effects.
   Evidence: We identified articles by Medline searches and supplemented them
with papers referenced in their bibliographies and those of reviews,
monographs, and textbooks. Two authors read each article in English that
appeared to meet a priori inclusion and exclusion criteria and completed a
data form for each article. All authors reviewed articles meeting inclusion
and exclusion criteria, and pertinent data were sorted into tables.
Prospective, randomized, controlled trials were accepted for analysis and
assessed individually, if of sufficient size. Trials of comparable agents were
consolidated by use of meta-analytic techniques. Searches, reviews, and tables
were completed in 1997; analyses and writing were done in 1998.

Recommendations:
   Acute uncomplicated bacterial cystitis. In otherwise healthy adult
nonpregnant women with acute uncomplicated bacterial cystitis, single-dose
therapy is generally less effective than the same antimicrobial used for
longer durations (A,I). However, most antimicrobials given for 3 days are as
effective as the same antimicrobial given for a longer duration (A,I).
   Trimethoprim-sulfamethoxazole for 3 days should be considered the current
standard therapy (A,I). Trimethoprim alone (A,II) and ofloxacin (A,I) are
equivalent to trimethoprim-sulfamethoxazole; other fluoroquinolones, such as
norfloxacin, ciprofloxacin, and fleroxacin, are probably of similar
effectiveness (A,II). Fluoroquinolones are more expensive than
trimethoprim-sulfamethoxazole and trimethoprim, and, to postpone emergence of
resistance to these drugs, we do not recommend them as initial empirical
therapy except in communities with high rates of resistance (i.e., >10%-20%)
to trimethoprim-sulfamethoxazole or trimethoprim among uropathogens. When
given for 3 days, Beta-lactams as a group are less effective than the foregoing
drugs (E,I). Nitrofurantoin and fosfomycin may become more useful as
resistance to trimethoprim-sulfamethoxazole and trimethoprim increase (B,I).
   Acute pyelonephritis. The few properly designed trials for management of
acute pyelonephritis are several years old, precluding recommendations firmly
based on recent evidence. For young nonpregnant women with nonnal urinary
tracts presenting with an episode of acute pyelonephritis, 14 days of
antimicrobial therapy is appropriate (A,I); courses of highly active agents as
short as 7 days may be sufficient for mild or moderate cases (B,I). Mild cases
can be managed with oral medications (A,II), and we recommend an oral
fluoroquinolone (A,II) or, if the organism is known to be susceptible,
trimethoprim-sulfamethoxazole (B,II). If a gram-positive bacterium is the
likely causative organism, amoxicillin or amoxicillin/clavulanic acid may be
used alone (B,III). Patients with more severe cases of acute pyelonephritis
should be hospitalized (A,II) and treated with a parenteral fluoroquinolone,
an aminoglycoside with or without ampicillin, or an extended-spectrum
cephalosporin with or without an aminoglycoside (B,III); if gram-positive
cocci are causative, we recommend ampicillin/sulbactam with or without an
aminoglycoside as therapy (B,III). With improvement, the patient's regimen
can be changed to an oral antimicrobial to which the organism is susceptible
to complete the course of therapy (B,III).
   These guidelines are based on antimicrobial susceptibilities reported in
the late 1990s, which are changing over time and vary geographically; thus, we
recommend that communities periodically reassess susceptibility of
uropathogens to commonly used antibiotics. Validation: This manuscript was
reviewed by infectious disease specialists and urologists interested in
urinary tract infections (see Acknowledgments), and many of their comments
have been incorporated. The conclusions were presented at the 1998 meeting of
the Infectious Diseases Society of America. Sponsors: This process was
sponsored by the Infectious Diseases Society of America and endorsed by the
American Urological Association.