C- 03: pyelonephritis
Diagnosis and Management of Urinary Tract Infections in the
Outpatient Setting : A Review
Larissa Grigoryan, MD, PhD; Barbara W. Trautner, MD, PhD; Kalpana Gupta, MD, MPH
Journal : AMA
Year : 2014
Volume : 312
Pages : 1677-1684.
ABSTRACT
Importance
Urinary tract infection is among the most common reasons for an outpatient visit and antibiotic
use in adult populations. The increasing prevalence of antibacterial resistance among
community uropathogens affects the diagnosis and management of this clinical syndrome.
Objectives
To define the optimal approach for treating acute cystitis in young healthy women and in women
with diabetes and men and to define the optimal approach for diagnosing acute cystitis in the
outpatient setting.
Evidence Review
Evidence for optimal treatment regimens was obtained by searching PubMed and the Cochrane
database for English-language studies published up to July 21, 2014.
Findings
Twenty-seven randomized clinical trials (6463 patients), 6 systematic reviews, and 11
observational studies (252 934 patients) were included in our review. Acute uncomplicated
cystitis in women can be diagnosed without an office visit or urine culture. Trimethoprimsulfamethoxazole (160/800 mg twice daily for 3 days), nitrofurantoin monohydrate/macrocrystals
(100 mg twice daily for 5-7 days), and fosfomycin trometamol (3 g in a single dose) are all
appropriate first-line therapies for uncomplicated cystitis. Fluoroquinolones are effective for
clinical outcomes but should be reserved for more invasive infections. β-Lactam agents
(amoxicillin-clavulanate and cefpodoxime-proxetil) are not as effective as empirical first-line
therapies. Immediate antimicrobial therapy is recommended rather than delayed treatment or
symptom management with ibuprofen alone. Limited observational studies support 7 to 14 days
of therapy for acute urinary tract infection in men. Based on 1 observational study and our
expert opinion, women with diabetes without voiding abnormalities presenting with acute cystitis
should be treated similarly to women without diabetes.
Conclusions and Relevance
Immediate antimicrobial therapy with trimethoprim-sulfamethoxazole, nitrofurantoin, or
fosfomycin is indicated for acute cystitis in adult women. Increasing resistance rates among
uropathogens have complicated treatment of acute cystitis. Individualized assessment of risk
factors for resistance and regimen tolerability is needed to choose the optimum empirical
regimen.
COMMENTS
This article is presently the most exhaustive and valuable synthesis on the subject. It could
serve as a reference for those implicated in basic clinical practice.
Urinary tract infections (UTIs) can be classified as different clinical syndromes depending on the
symptoms and host characteristics. The most common form of UTI is acute uncomplicated
cystitis, defined as the acute onset of dysuria, frequency, or urgency in a healthy, nonpregnant
woman without known functional or anatomical abnormalities of the urinary tract.
In men, UTI is frequently associated with bacterial colonisation of the prostate which needs a
sustained treatment.
In this article, the diagnosis of UTI is reviewed with an emphasis on management strategies.
Evidence regarding the optimal therapies for uncomplicated acute cystitis in young healthy
women, in women with diabetes, and in men with UTI is specifically addressed. PubMed and
the Cochrane database were searched for English-language studies published before July 21,
2014, on optimal treatment regimens.
. After excluding ineligible studies on treatment, 33 studies on treatment of UTI were included in
the final review
Definitions of Research and Clinical End Points

Clinical cure: resolution or improvement of symptoms.a

Microbiological (bacterial) cure: a urine culture that is negative or a reduction in the
uropathogen colony count.b

Early cure, clinical or microbiological: infection resolution within 2 weeks of treatment
initiation.a

Late cure, clinical or microbiological: infection resolution at 4 to 6 weeks after treatment
initiation.a

Uncomplicated urinary tract infection: the acute onset of dysuria, frequency, or urgency
in a healthy, nondiabetic, adult, nonpregnant woman without known functional or
anatomical abnormalities of the urinary tract.

High-quality trial: a trial with a large sample size that includes a clearly specified
randomization plan, blinding, and follow-up of more than 80%.
a
The definition of cure, whether clinical or microbiological, can vary by study.
b
The amount of reduction in the uropathogen colony count varies by study.
Clinical trial evidence supports trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3
days), nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5-7 days), and
fosfomycin trometamol (3 g in a single dose) as first-line therapies for uncomplicated cystitis.
The choice between these agents should be influenced by individual factors such as resistance
prevalence, cost, and tolerability. The rate of resistance among Escherichia coli to the
fluoroquinolones (~20%) is about 10-fold higher than to fosfomycin (1%-2%) and is increasing.
Men with acute cystitis should be treated for 7 to 14 days. One of the most controversial issues
in UTI management is whether diabetic women with acute cystitis should receive the same
treatment as nondiabetic women or whether risk stratification of diabetic women for a longer or
different type of therapy is necessary based on diabetes-related complications such as
neurogenic bladder.
Immediate antimicrobial therapy with trimethoprim-sulfamethoxazole, nitrofurantoin, or
fosfomycin is indicated for acute cystitis in adult women. Increasing resistance rates among
uropathogens have complicated treatment of acute cystitis, but telephone management without
an office visit or culture is still an appropriate and efficient approach for most cases of
uncomplicated cystitis.
Pr. Jacques CHANARD
Professor of Nephrology