AUA Guidelines on Recurrent Uncomplicated Urinary Tract Infections in Women
The American Urological Association (AUA) has issued its first guideline for the diagnosis and treatment of uncomplicated recurrent urinary tract infections (UTIs), emphasizing the importance of cultures and antibiotic stewardship. [48]
Evaluation
Women presenting with recurrent lower urinary tract infections (rUTI) should undergo a complete patient history and pelvic examination.
A diagnosis of rUTI must be based on documented positive urine culture results in association with prior symptomatic episodes.
An initial urine specimen that may be contaminated should prompt a repeat urine study; collection of a catheterized specimen should be considered.
Index patients presenting with rUTI should not routinely undergo upper tract imaging and cystoscopy.
Before beginning treatment in patients with rUTI, urinalysis, urine culture, and sensitivity should be performed for each symptomatic acute cystitis episode.
Select patients with rUTI with acute episodes may be offered patient-initiated treatment (self-start treatment) while urine culture results are pending.
Asymptomatic bacteriuria
Surveillance urine testing, including urine culture, should not be performed in asymptomatic patients with rUTI.
Asymptomatic bacteriuria should not be treated.
Antibiotic treatment
Symptomatic UTIs in women should be treated with first-line therapy (ie, nitrofurantoin, TMP-SMX, fosfomycin) and should depend on local antibiogram.
The duration of antibiotic therapy for rUTI in patients with acute cystitis episodes should be as short as is reasonable (typically no longer than 7 days).
rUTIs in patients with acute cystitis that has shown resistance to oral antibiotics on urine culture may be treated with culture-directed parenteral antibiotics for as short a course as is reasonable (typically no longer than 7 days).
Antibiotic prophylaxis
After discussing the risks, benefits, and alternatives, antibiotic prophylaxis may be prescribed to reduce the risk for future UTIs in women of all ages previously diagnosed with UTI.
Nonantibiotic prophylaxis
Cranberry prophylaxis may be offered to women with rUTI.
Follow-up evaluation
Posttreatment urinalysis or urine culture to test for cure should not be performed in asymptomatic patients.
UTI symptoms that persist after antimicrobial therapy should prompt repeat urine culture to guide further treatment.
Estrogen therapy
Vaginal estrogen therapy with no contraindications should be recommended to perimenopausal and postmenopausal women with rUTIs to reduce the risk of future UTI.
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Nonobstructing distal left ureteral calculus 2 X 1 X 2 cm.
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Multiple abscesses, upper pole of left kidney.
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Bilateral hydronephrosis.
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Plain radiograph in a 63-year-old patient with poorly controlled type 2 diabetes mellitus shows emphysematous cystitis.
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Lactobacilli and a squamous epithelial cell are evident on this vaginal smear. The presence of squamous cells and lactobacilli on urinalysis suggests contamination or colonization. Source: Centers for Disease Control and Prevention, Dr. Mike Miller
Tables
First-line therapy |
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Second-line therapy |
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Alternative therapy |
*Should generally be avoided in elderly patients because of the risk of affecting renal function. |
First-line therapy |
Oral: Patients with complicated cystitis who can tolerate oral therapy may be treated with the following options:
Parenteral: Patients who cannot tolerate oral therapy as outlined above or patients with infection that is suspected to be due to resistant organisms should be treated with parenteral therapy, as follows:
Duration of therapy: Shorter courses (7d) are reasonable if patient improves rapidly; longer courses (10-14d) are reasonable if patient has a delayed response or is hospitalized.
Parenteral therapy can be switched to oral therapy once clinical improvement is observed. |
Second-line therapy |
Duration of therapy: Shorter courses (7d) are reasonable if patient improves rapidly; longer courses (10-14d) are reasonable if patient has a delayed response or is hospitalized.
Parenteral therapy can be switched to oral therapy once clinical improvement is observed. |
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- Complicated Cystitis in Nonpregnant Women
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