Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
The following is a summary of the recommendations for uncomplicated urinary tract infections in adults. Refer to the original guideline for more detailed recommendations and discussion.
Levels of evidence (Ia-IV) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Definition of Uncomplicated Urinary Tract Infection (UTI)
Acute, uncomplicated UTIs in adults include episodes of acute cystitis and acute pyelonephritis in otherwise healthy individuals. These UTIs are seen mostly in women who have none of the factors known to increase the risk of complications or of treatment failure.
Acute Uncomplicated Cystitis in Pre-menopausal, Non-pregnant Women
Besides physical examination, urinalysis (e.g., using a dipstick method), including the assessment of white and red blood cells and nitrites, is recommended for routine diagnosis (B). Colony counts >103 colony forming units (cfu) uropathogen/mL are considered to be a clinically relevant bacteriuria (IIb).
Short courses of antimicrobials are highly effective and are desirable because of the improved compliance that they promote, their lower cost and lower frequency of adverse reactions. Single-dose therapy (with some exceptions) is generally less effective than the same antibiotic used for a longer duration. However, with most suitable antimicrobials, there is little to be gained from treatment given beyond 3 days and the risk of adverse events is higher (IaA).
Trimethoprim (TMP) or TMP-sulphamethoxazole (SMX) can only be recommended as first-line drugs for empirical therapy in communities with rates of uropathogen resistance to TMP of less than 20% (IbA). Otherwise, fluoroquinolones, fosfomycin trometamol, pivmecillinam and nitrofurantoin are recommended as alternative oral drugs for empirical therapy. However, in some areas, the rate of fluoroquinolone-resistant Escherichia coli (E. coli) is also increasing.
Urinalysis, including a dipstick method, is sufficient for routine follow-up. Post-treatment cultures in asymptomatic patients may not be indicated. In women whose symptoms do not resolve, or which resolve and then recur within 2 weeks, urine culture and antimicrobial susceptibility testing should be performed (IVC).
Acute Uncomplicated Pyelonephritis in Pre-menopausal, Non-pregnant Women
Acute pyelonephritis is suggested by flank pain, nausea and vomiting, fever (>38 degrees C), or costovertebral angle tenderness. It may occur in the absence of cystitis symptoms (e.g., dysuria, frequency). Besides physical examination, urinalysis (e.g., using a dipstick method), including the assessment of white and red blood cells and nitrites, is recommended for routine diagnosis (C). Colony counts >104 cfu uropathogen/mL can be considered to be a clinically relevant bacteriuria (IIb).
An evaluation of the upper urinary tract with ultrasound should be performed to rule out urinary obstruction or renal stone disease (C). Additional investigations, such as an unenhanced helical computed tomography (CT), an excretory urogram, or dimercaptosuccinic acid (DMSA) scan, should be considered if the patients remain febrile after 72 hours of treatment to rule out further complicating factors (e.g., urolithiasis, renal or perinephric abscesses). (C).
As first-line therapy in mild cases, an oral fluoroquinolone for 7 days is recommended in areas where the rate of fluoroquinolone-resistant E. coli is still low (<10%) (IbA). If a Gram-positive organism is seen on the initial Gram stain, an aminopenicillin plus a beta-lactamase inhibitor (BLI) could be recommended (IIbB). More severe cases of acute uncomplicated pyelonephritis should be admitted to hospital and treated according to the patient's condition parenterally with a fluoroquinolone (ciprofloxacin or levofloxacin), a third-generation cephalosporin or an amino/acylaminopenicillin plus a BLI according to the local susceptibility pattern (IIbB). With improvement, the patient can be switched to an oral regimen using a fluoroquinolone or TMP-SMX (if active against the infecting organism) to complete the 1- or 2-week course, respectively (IIbB). In areas with increased resistance rate of E. coli against fluoroquinolones and in situations in which fluoroquinolones are contraindicated (e.g., pregnancy, lactating women, adolescence), a second- or third-generation oral cephalosporin is recommended (IIbB).
Routine post-treatment cultures in an asymptomatic patient may not be indicated; routine urinalysis using a dipstick method is sufficient (IIbB). In women whose symptoms of pyelonephritis resolve but then recur within 2 weeks, it is important to carry out a repeat urine culture, antimicrobial susceptibility testing, and an appropriate investigation to rule out urinary tract abnormalities (C).
Recurrent (Uncomplicated) UTIs in Women
Recurrent UTIs (RUTIs) are common among young, healthy women, even though they generally have anatomically and physiologically normal urinary tracts. The following prophylactic antimicrobial regimens are recommended:
- Long-term, low-dose prophylactic antimicrobials taken at bedtime (IaA)
- Post-intercourse prophylaxis for women in whom episodes of infection are associated with sexual intercourse (IbA)
- A patient-initiated treatment may also be suitable for management of RUTIs in well-informed, young women (IIaB).
Prophylactic alternative methods include immunotherapy (IaB) and probiotic therapy (IIaC), acidification (IIaC), and cranberry juice (IIaC). These regimens are not yet as effective as antimicrobial prophylaxis, though directly comparative studies have not been performed.
UTIs in Pregnancy
Urinary tract infections are common during pregnancy. Most women acquire bacteriuria before pregnancy, while 20-40% of women with asymptomatic bacteriuria will develop pyelonephritis during pregnancy. Treatment of asymptomatic bacteriuria lowers this risk (IIa).
Most symptomatic UTIs in pregnant women present as acute cystitis. Short-term therapy is not as established as in non-pregnant women. For a recurrent UTI, low-dose cephalexin (125-250 mg) or nitrofurantoin (50 mg) at night is recommended for prophylaxis against re-infection (IbA). Post-intercourse prophylaxis may be an alternative approach (IbA).
For acute pyelonephritis, second- or third-generation cephalosporins, an aminoglycoside, or an aminopenicillin plus a BLI may be recommended antibiotics (IIbB). During pregnancy, quinolones, tetracyclines and TMP are contraindicated in the first trimester, while sulphonamides should not be used in the last trimester (IIbB). In cases of delayed defervescence and upper tract dilatation, a ureteral stent may be indicated and antimicrobial prophylaxis should be considered until delivery (IIbB).
UTIs in Post-menopausal Women
In acute cystitis, the antimicrobial treatment policy in post-menopausal women is similar to that in pre-menopausal women. However, short-term therapy in post-menopausal women is not as well documented as that in younger women. In the case of a recurrent UTI, urological or gynaecological evaluation should be performed in order to eliminate a tumour, obstructive problems, detrusor failure or a genital infection (IIIB).
In post-menopausal women with a recurrent UTI, therapy with intravaginal oestriol is able to reduce significantly the rate of recurrences (IbA). For the remainder of patients, an antimicrobial prophylactic regimen should be recommended in addition to hormonal treatment (IIIB).
For acute pyelonephritis, the same treatment modalities are recommended as for pre-menopausal, non-pregnant women (see the section "Acute Uncomplicated Pyelonephritis in Pre-menopausal, Non-pregnant Women," above).
Acute Uncomplicated UTIs in Young Men
Only a small number of 15 to 50-year-old men suffer from acute uncomplicated UTI. Such men should receive, as minimum therapy, a 7-day antibiotic regimen (IIaB). Most men with febrile UTI have a concomitant infection of the prostate, as measured by transient increases in serum PSA and prostate volume (IIa). Urological evaluation should be carried out routinely in adolescents and men with febrile UTI, pyelonephritis, recurrent infections, or whenever a complicating factor is suspected (IIIB). A minimum treatment duration of 2 weeks is recommended (IIIB), preferably with a fluoroquinolone since prostatic involvement is frequent.
Asymptomatic Bacteriuria
Asymptomatic bacteriuria is common. Populations with structural or functional abnormalities of the genitourinary tract may have an exceedingly high prevalence of bacteriuria, but even healthy individuals frequently have positive urine cultures. Asymptomatic bacteriuria is seldom associated with adverse outcomes. Screening for, or treatment of, asymptomatic bacteriuria is not recommended for the following persons:
- Pre-menopausal, non-pregnant women (IbA)
- Diabetic women (IbA)
- Older persons living in community (IIaB)
- Elderly institutionalized subjects (IIaB)
- Persons with spinal cord injury (IIaB)
- Catheterized patients while the catheter remains in situ (IbA)
Screening for asymptomatic bacteriuria and treatment is recommended only for selected groups where benefit has been shown: pregnant women (IbA); before transurethral resection of the prostate (TURP) (IbA) and other traumatic urological interventions (IIIB). Antimicrobial therapy should be initiated shortly before the procedure (IIIB).
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis of randomized trials
Ib Evidence obtained from at least one randomized trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study
III Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
IV Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
