Uncomplicated Bacterial Community-Acquired Urinary Tract Infection in Adults

Abstract

Background: Uncomplicated bacterial community-acquired urinary tract infection is among the more common infections in outpatient practice. The resistance level of pathogens has risen markedly. This S3 guideline contains recommendations based on current evidence for the rational use of anti - microbial agents and for the prevention of inappropriate use of certain classes of antibiotics and thus of the resulting drug resistance. The prevention of recurrent urinary tract infection is considered in this guideline for the first time.

Methods: The guideline was updated under the aegis of the German Urological Society (Deutsche Gesellschaft für Urologie). A systematic literature search (period: 2008-2015) concerning the diagnosis, treatment, and prevention of uncomplicated urinary tract infections was carried out in the Cochrane Library, MEDLINE, and Embase databases. Randomized, controlled trials and systemic reviews were included. Relevant guidelines were identified in a guideline synopsis.

Results: Symptom-oriented diagnostic evaluation is highly valued. For the treatment of cystitis, fosfomycin-trometamol, nitrofurantoin, nitroxolin, pivmecillinam and trimethoprim are all equally recommended. Fluorquinolones and cephalosporins are not recommended. Uncomplicated pyelonephritis with a mild to moderate clinical course ought to be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For acute, uncomplicated cystitis, with mild to moderate symptoms, symptomatic treatment alone may be considered instead of antibiotics after discussion of the options with the patient. Mainly non-antibiotic measures are recommended for prophylaxis against recurrent urinary tract infection.

Conclusion: Physicians who treat uncomplicated urinary tract infections should familiarize themselves with the newly revised guideline's recommendations on the selection and dosage of antibiotic treatment so that they can responsibly evaluate and plan antibiotic treatment for their affected patients.

eFigure 1

Flow chart of literature survey according to PRISMA statement (11)

eFigure 2

The figure depicts the derivation of the recommendation strength from the evidence level. Normally a high level of evidence translates into a strong recommendation. However, provided the grading criteria (consistency of study results, clinical relevance of endpoints, effect size, risk–benefit ratio, and applicability/implementability in the German health care system) are taken into account, the guideline group can up- or downgrade the strength of recommendation (modified from: German Association of the Scientific Medical Societies (AWMF) Standing Guidelines Commission. AWMF Guidance Manual and Rules for Guideline Development, 1^st edition 2012. English version. Available at: http://www.awmf.org/leitlinien/awmf-regelwerk.html (last accessed on July 30, 2017).

eFigure 3

Decision tree – diagnosis and treatment in symptomatic patients (clinical–microbiological diagnostic pathway), www.awmf.org/leitlinien/detail/ll/043–044.html * On the initial manifestation of acute urinary tract infection, or if the patient is unknown to the physician, the medical history should be documented and a symptom-oriented medical examination carried out.

eFigure 4

Clinical procedure in acute pyelonephritis in adult women, www.awmf.org/leitlinien/detail/ll/043–044.html

eFigure 5

British version of the ACSS questionnaire on the clinical diagnosis of acute, uncomplicated cystitis in women: Part A (first visit) (The questionnaire is available for download in multiple languages at www.acss.world).