Consensus statement
Executive summary of the diagnosis and treatment of urinary tract infection: Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC)Resumen ejecutivo del diagnóstico y tratamiento de las infecciones del tracto urinario. Guía de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC)

https://doi.org/10.1016/j.eimc.2016.11.005Get rights and content

Abstract

Most urinary tract infections (UTI) are uncomplicated infections occurring in young women. An extensive evaluation is not required in the majority of cases, and they can be safely managed as outpatients with oral antibiotics. Escherichia coli is by far the most common uropathogen, accounting for >80% of all cases. Other major clinical problems associated with UTI include asymptomatic bacteriuria, and patients with complicated UTI. Complicated UTIs are a heterogeneous group associated with conditions that increase the risk of acquiring infection or treatment failure. Distinguishing between complicated and uncomplicated UTI is important, as it influences the initial evaluation, choice, and duration of antimicrobial therapy. Diagnosis is especially challenging in the elderly and in patients with in-dwelling catheters. The increasing prevalence of resistant uropathogens, including extended-spectrum β-lactamases and carbapenemase-producing Enterobacteriaceae, and other multidrug-resistant Gram-negative organisms further compromises treatment of both complicated and uncomplicated UTIs.

The aim of these Clinical Guidelines is to provide a set of recommendations for improving the diagnosis and treatment of UTI.

Resumen

La mayoría de infecciones del tracto urinario (ITU) son infecciones no complicadas que se presentan en mujeres jóvenes. En la mayoría de los casos no se requieren pruebas diagnósticas complementarias y se pueden tratar ambulatoriamente de forma segura con antibióticos por vía oral. Escherichia coli es el uropatógeno más frecuente causando más del 80% de estas infecciones. La bacteriuria asintomática (BA) y las ITUs complicadas son otras formas de presentación de la ITU. Las ITU complicadas son un grupo heterogéneo de condiciones que incrementan el riesgo de adquisición de la infección o de fracaso del tratamiento. La distinción entre ITU complicada y no complicada es fundamental para decidir la evaluación inicial del paciente, la elección del antimicrobiano y la duración del mismo. El diagnóstico es especialmente difícil en ancianos y en pacientes con sondaje permanente. El incremento de cepas resistentes a los antibióticos, especialmente Enterobacterías productoras de beta-lactamasas de espectro extendido y de carbapenemasas y de otros Gram negativos multirresistentes, dificultan la elección del tratamiento de las ITU complicadas y no complicadas.

El objetivo de esta guía clínica es proporcionar recomendaciones basadas en la evidencia para mejorar el diagnóstico y tratamiento de las ITU.

Introduction

Urinary tract infection (UTI) is one of the most common clinical problems in both the community and healthcare-associated settings. Community-acquired uncomplicated UTIs (uUTI) are particularly common among women, the vast majority of whom experience at least one episode of infection in their lifetime. A significant subset (25–40%) of women also develop recurrent urinary tract infections (rUTI), with multiple infections that recur over months, or years, in some cases. Other relevant clinical problems associated with UTI include asymptomatic bacteriuria (AB) and patients with complicated urinary tract infection (cUTI). Nosocomial UTI (generally a reflection of catheter-associated infections) constitutes about 20–30% of all hospital-acquired infections and are common sources of nosocomial bacteremia. One of the most important factors impacting the management of UTI in recent years has been the emergence of antimicrobial resistance among uropathogens, particularly isolates causing community-acquired UTI. Although at the moment antimicrobials can generally ensure the successful treatment or prevention of UTI, the emergence of antimicrobial resistance among uropathogens may soon limit our ability to do so.

All the above reasons illustrate how variable and complex these infections are, which is why the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC) requested a panel of experts to provide an update on many of the issues involved, including the aetiology, microbiology, prevention, diagnosis, and treatment of various UTI syndromes. The related topic of prostatitis falls outside the scope of these guidelines. The present statement was written following SEIMC guidelines for consensus statements (www.seimc.org), as well as Agree Collaboration (www.agreecollaboration.org) recommendations for evaluating the methodological quality of clinical practice guidelines. Over various meetings, the authors selected a set of questions designed to form the basis of the document. Their recommendations are based on a systematic critical review of the literature including, when necessary, the opinion of experts, who are SEIMC members. Their recommendations have been adjusted according to the scientific evidence available (Appendix A). All the authors and the coordinators of the statement have agreed on the contents and conclusions of the document. Before final publication, the manuscript was made available online for all SEIMC members to read and to make comments and suggestions.

Section snippets

What microbiological and clinical data should be used to guide empiric treatment of UTI?

Recommendations:

  • Studies of the susceptibility of uropathogens in the community tend to overestimate resistance rates. To guide empiric treatment, susceptibility and clinical data (type of UTI (uncomplicated versus complicated), sex, age and previous antibiotic therapy should be considered (A-II)).

  • An antimicrobial agent is not recommended for empiric treatment of urinary tract infections if local resistance prevalence is over 20% for cystitis (B-II) or 10% for pyelonephritis (C-III).


When is a urine culture necessary for the diagnosis of uncomplicated cystitis?

Recommendations:

  • In women with uncomplicated cystitis, empiric treatment should be initiated on the basis of symptoms alone. A urine culture is generally not necessary (E-I).

  • A pre-treatment urine culture should be obtained when the diagnosis is not clear from the history and physical examination, when the episode represents an early symptomatic recurrence, when there is reason to suspect antimicrobial resistance or the patient's therapeutic options are limited due to medication intolerance (A-II

Which pharmacokinetic/pharmacodynamics parameters of an antibiotic describe exposure-response relationships in general?

Recommendations:

  • Bacterial killing is best described by indices incorporating the antimicrobial's PK and PD parameters and the minimum inhibitory concentration (MIC), the lowest concentration of the antimicrobial required to prevent the growth of the target organism (B-II).


Are urine-specific breakpoints necessary?

Recommendations:

  • Specific susceptibility breakpoints for UTI isolates are recommended (B-III). EUCAST and CLSI have published several breakpoints that are valid only for isolates in uncomplicated urinary tract infections.


Is the antibiotic concentration in serum or urine the most important?

Is pyuria useful for diagnosing asymptomatic bacteriuria?. Are urine rapid tests recommended for screening of asymptomatic bacteriuria?

Recommendations:

  • Pyuria cannot be considered as an adequate criterion for the diagnosis of AB nor for indication for treatment in a patient with AB (A-II). Urine test stripes are not recommended for the detection of AB (A-II).


Pregnant women

Recommendations:

  • Systematic screening and treatment of AB is recommended for pregnant women (A-I) in order to reduce the risk of pyelonephritis (A-I), preterm labour and low birth weight infants (B-II). An initial urine culture between the 12th and 16th weeks of pregnancy is recommended (A-I).

  • A follow-up urine culture is recommended in order to verify that the bacteriuria has been eradicated (A-III). Subsequent monthly urine cultures until delivery are recommended (C-III).


Patients who must undergo urological procedures

Recommendations:

For pregnant women with asymptomatic bacteriuria

Recommendation:

  • Standard 4- to 7-day treatment regimens are better than short one-day treatments for eradicating bacteriuria (A-I). Only a single 3 g dose of FT offers similar results to the standard treatment regimen (A-I).


What is the first-choice empiric antibiotic treatment recommended for acute uncomplicated cystitis?

Recommendations:

  • Due to minimal resistance and propensity for collateral damage, fosfomycin-trometamol (3 g in a single dose) and nitrofurantoin (for 5–7 days) are considered the first-choice drugs for therapy of uncomplicated cystitis (A-I).

  • Fluoroquinolones (ciprofloxacin, levofloxacin and norfloxacin) are highly efficacious in 3-day regimens (A-I), but should be considered as alternative antimicrobials because of their high propensity for collateral damage (B-III).

  • β-Lactam agents, including

What are the criteria for hospital admission in adult patients?

Recommendations:

  • Women with uncomplicated APN and mild to moderate symptoms (fever <39 °C, no severe flank pain, no vomiting) can be treated as outpatients (A-II).

  • Women with uncomplicated APN but with social, mental or physical disabilities that might hinder adherence to a prescribed therapeutic regimen should be admitted to hospital (C-III).

  • Women with uncomplicated APN and severe symptoms (fever ≥39 °C, severe flank pain, vomiting) should be referred to an emergency room for evaluation,

What is the etiology of UTI in patients with urinary catheters?

Recommendations:

  • In patients with short-term catheterization, UTI is usually monomicrobial and frequently caused by Enterobacteriaceae (B-II).

  • In patients with long-term catheterization, UTI is usually polymicrobial and frequently caused by antimicrobial-resistant bacteria (B-II).


What are the clinical and microbiologial features for diagnosis of symptomatic CA-UTI?

Recommendations:

  • If an indwelling catheter has been in place for >2 weeks, the catheter should be replaced before obtaining urine for culture (A-II).

  • Signs and symptoms compatible with CA-UTI include fever, rigors, altered

What are the main risk factors of rUTI in premenopausal women?

Recommendations:

  • In sexually active women, the main risk factor for rUTI is frequency of sexual intercourse (B-I).

  • In sexually active women with rUTI, it is not necessary to perform a urological study if there is no suspicion of underlying urological disease (A-II).


Are hygienic measures effective in preventing rUTI?

Recommendation:

  • In women who fail to prevent rUTI with hygiene measures, it is not necessary to insist on their implementation (B-II).


Is acidification of the urine useful for preventing rUTI?

Recommendations:

  • Vitamin C (ascorbic acid) in acceptable dosing intervals in regular clinical practice

Conflict of interest

The authors declare no conflicts of interest.

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