• American College of Obstetricians and Gynecologists (ACOG). Treatment of urinary tract infections in nonpregnant women. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2008 Mar. 10 p. (ACOG practice bulletin; no. 91). [51 references]

This is the current release of the guideline.

Urinary tract infections

• Acute bacterial cystitis
• Acute pyelonephritis

Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment

Family Practice
Internal Medicine
Obstetrics and Gynecology
Urology

Physicians

• To aid practitioners in making decisions about appropriate obstetric and gynecologic care
• To address the diagnosis, treatment, and prevention of uncomplicated acute bacterial cystitis and acute bacterial pyelonephritis in nonpregnant women

Nonpregnant women with uncomplicated urinary tract infections (UTIs)

Note: Women with complicated UTIs (e.g., in patients with diabetes mellitus, abnormal anatomy, prior urologic surgery, a history of renal stones, an indwelling catheter, spinal cord injury, immunocompromise, or in pregnant patients) are a heterogeneous group of conditions beyond the scope of this guideline.

Evaluation and Diagnosis

1. Differential diagnosis: acute bacterial cystitis versus acute pyelonephritis
   • Clinical history and physical examination
   • Laboratory evaluation of bacteriuria and pyuria
     • Urine dipstick testing
     • Urine culture or urinalysis
2. Risk factor assessment for urinary tract infection (UTI) in premenopausal and postmenopausal women
3. Risk factor assessment for recurrent UTI
4. Imaging of the urinary tract (not recommended routinely for uncomplicated UTIs)
5. Screening for asymptomatic bacteriuria in nonpregnant, premenopausal women (considered but specifically not recommended)

Treatment and Management

1. Antimicrobial regimens for uncomplicated UTIs (3-day vs. 7-day)
   • Trimethoprim-sulfamethoxazole
   • Trimethoprim
   • Ciprofloxacin
   • Levofloxacin
   • Norfloxacin
   • Gatifloxacin
   • Nitrofurantoin macrocrystals and nitrofurantoin monohydrate macrocrystals
   • Fosfomycin tromethamine
2. Use of 14-day antimicrobial regimens for acute pyelonephritis
3. Management of recurrent UTI
   • Prophylactic or intermittent antimicrobial therapy
   • Cranberry juice
   • Methenamine salts (not sufficient evidence for use)
4. Treatment of UTIs in postmenopausal women

• Incidence of acute bacterial cystitis
• Incidence of acute pyelonephritis
• Incidence of recurrent urinary tract infections
• Effectiveness of antimicrobial therapy (clinical response and bacterial eradication rates)
• Sensitivity and specificity of diagnostic tests
• Adverse effects of treatment

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and April 2007. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I Evidence obtained from at least one properly designed randomized controlled trial.

II-1 Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

Published cost analyses were reviewed.

Internal Peer Review

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):

• Screening for and treatment of asymptomatic bacteriuria is not recommended in nonpregnant, premenopausal women.
• Resistance rates higher than 15 to 20% necessitate a change in antibiotic class.
• In all cases of acute pyelonephritis, whether treatment is on an inpatient or outpatient basis, 14 days of total antimicrobial therapy should be completed.
• A 3-day antimicrobial regimen is the preferred treatment duration for uncomplicated acute bacterial cystitis in women, including women aged 65 years and older.

The following conclusion is based on limited or inconsistent evidence (Level B):

• The initial treatment of a symptomatic lower urinary tract infection (UTI) with pyuria or bacteriuria or both does not require a urine culture.

The following conclusions are based primarily on consensus and expert opinion (Level C):

• Beta-lactams, such as first-generation cephalosporins and amoxicillin, are less effective in the treatment of acute uncomplicated cystitis than those antimicrobials listed in the Table below.
• To diagnose bacteriuria, decreasing the colony count to 1,000 to 10,000 bacteria per milliliter in symptomatic patients will improve the sensitivity without significantly compromising specificity.

Table. Treatment Regimens for Uncomplicated Acute Bacterial Cystitis

Definitions:

Grades of Evidence

I Evidence obtained from at least one properly designed randomized controlled trial.

II-1 Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendation

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Accurate diagnosis and appropriate management of urinary tract infections in nonpregnant women

Adverse events associated with antimicrobial treatment regimens (see Table 1 in the original guideline document).

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Getting Better
Staying Healthy

Effectiveness

• American College of Obstetricians and Gynecologists (ACOG). Treatment of urinary tract infections in nonpregnant women. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2008 Mar. 10 p. (ACOG practice bulletin; no. 91). [51 references]

Not applicable: The guideline was not adapted from another source.

2008 Mar

American College of Obstetricians and Gynecologists - Medical Specialty Society

American College of Obstetricians and Gynecologists (ACOG)

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins - Gynecology

Not stated

Not stated

This is the current release of the guideline.

Proposed performance measures are included in the original guideline document.

This NGC summary was completed by ECRI Institute on July 30, 2008. The information was verified by the guideline developer on August 20, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.