Urinary Infection In Adults- Recommended Treatment

Urinary Infection In Adults
Urinary Infection In Adults
Urinary infections (UTIs) are classified into simple or complicated in relation to the presence or absence of risk factors that can make the course more severe and the treatment more complex ( Table ). 

  • Simple acute cystitis
  • Complicated cystitis
  • Relapsing cystitis
  • Acute pyelonephritis
  • Acute prostatitis

Urinary infections in pregnancy:

  1. asymptomatic bacteriuria
  2. acute cystitis
  3. acute pyelonephritis
  4. Bibliography

Terminology

Simple urinary infections include cystitis and pyelonephritis simple; they concern only the young woman without risk factors and the woman aged> 65 years without comorbidities. Some "simple" cystitis and pyelonephritis can have a severe evolution (eg urosepsis). 

The complicated urinary infections include complicated cystitis and pyelonephritis, prostatitis. By definition, men cannot have a simple urinary infection, as anatomical or functional abnormalities and/or posterior urethra, prostate, or epididymal infections are often present, which must always be sought. Treatment (with some exceptions) is similar to that of prostatitis. 

This is referred to as urinary colonization  (or asymptomatic bacteriuria) the situation characterized by the presence of urinary pathogens (detected by microbiological examination), but the absence of clinical signs. No antibiotic treatment is recommended (Grade A). Non-treatment does not lead to an increased risk of complications. In the non-catheterized elderly, asymptomatic bacteriuria can persist for 2-3 years without causing an increase in mortality. Bladder washes should be avoided in catheterized patients. If infectious symptoms (e.g. fever, neurological disorders) appear, the catheter must be changed before the urine sample is collected.  

Simple acute cystitis

Recommended tests: dipstick for urinary esterase and nitrite.

Empirical Treatment :

-1 to   choice: fosfomycin trometamol, in a single dose (an envelope) (Grade A);

-2 of your choice: nitrofurantoin for 5 days. In case of intolerability: fluoroquinolone 1 to generation (norfloxacin) in a single dose or for 3 days (Grade A).

Empirical therapy scheme of simple or relapsing acute cystitis in adults with normal renal and hepatic function

  • Chemotherapy

Dosage and duration

  • Phosphomycin trometamol 3g os in a single dose
  • 1 of your  choice
  • Nitrofurantoin 100 mg os x 3 / day, for 5 days
  • 2 of your  choice
  • Norfloxacin 400 mg os x 2 / day, for 3 days
  • 2 of your  choice

Not recommended in relapsing forms 

Urinary Infection In Adults
Urinary Infection In Adults

Notes

- Agriculture is not routinely indicated; the examination should be performed only in case of persistence of clinical symptoms/signs after 3 days of therapy (possible therapeutic failure) or in case of relapse. 

- Urinalysis and uroculture should not be repeated at the end of the treatment if the patient no longer has symptoms.

- Fosfomycin trometamol and fluoroquinolones in single doses are not very effective against  Staphylococcus saprophyticus: in the presence of risk factors for this pathogen (woman <30 years and negative nitrites in the urine) a treatment with nitrofurantoin for 5 days or with fluoroquinolone for 3 days.

- Amoxicillin, amoxicillin-clavulanic acid, and co-trimoxazole should not be used in empirical therapy due to the high prevalence of resistance by urinary pathogens.

- In the case of single-dose treatment, the patient should be informed that the symptoms may persist for 2-3 days.

Complicated cystitis

Recommended tests: dipstick for urinary esterase and nitrite + uroculture.

Empirical treatment  (if it can not be deferred in expectation of 'susceptibility):

- 1 to  choice: nitrofurantoin;

- 2 to  choose: cefixime or a systemic fluoroquinolone (eg. Ciprofloxacin

Targeted treatment based on the antibiogram  (if therapy can be deferred for 48 hours). With the same sensitivity, choose the antibiotic according to these priorities:

- penicillins and cephalosporins

- nitrofurantoin

- co-trimoxazole

The total duration of treatment: 5 days, except for nitrofurantoin 7 days. In the presence of specific clinical conditions, the treatment can be prolonged. 

Complicated cystitis: empirical therapy

  • Chemotherapy

Dosage and duration

Nitrofurantoin

100 mg os x 3 / day, for 7 days

Extension of treatment duration if clinical conditions require it

Cefixime

200 mg os x 2 / day, for 5 days

Ciprofloxacin

500-750 mg os x 2 / day, for 5 days

Levofloxacin

500 mg os/day, for 5 days

Norfloxacin

400 mg os x 2 / day, for 5 days

Complicated cystitis: targeted therapy

Chemotherapy

Dosage and duration

Amoxicillin

1g os x 3 / day, for 5 days

Extension of treatment duration if clinical conditions require it

Amoxicillin-ac clavulanic

1g os x 3 / day, for 5 days

Cotrimoxazole

(SMX 800mg + TMP 160mg)

1 tablet os x 2 / day, for 5 days

Notes

-  Before starting antibiotic therapy, uroculture with sensitivity tests must be performed.

- If at the end of the treatment the patient has no more symptoms, it is not recommended to repeat the uroculture to evaluate the healing. If, on the other hand, the patient is still symptomatic, the uroculture must be repeated.  

- The 1 fluoroquinolones to generation are not recommended, even though the isolated pathogen is sensitive.

- Avoid fluoroquinolones if the antibiogram reveals quinolone resistance of 1 to generation as this often constitutes a likelihood of selection of a mutant with a high resistance level (Grade A).

- Avoid single-dose treatments (phosphomycin and fluoroquinolones) or short-term (fluoroquinolone for 3 days).

Relapsing cystitis

Definition: at least 4 episodes in 12 months.

Recommended tests: uroculture (at least once).

Curative treatment:  the same for simple cystitis; possibility of self-management by the patient, after education, depending on the result of a complete urinalysis.

Prophylactic treatment: to be evaluated case by case.

Curative treatment

An Etiological diagnosis is necessary. The therapeutic schemes are similar to those of simple cystitis; do not always use the same molecule. 

Repeat culture is recommended in case of recurrence less than 7 days after the previous episode. Imaging investigations to assess for urinary tract abnormalities are not indicated. In case of isolation of  Proteus sp, a renal ultrasound should be performed to exclude stones. It is advisable to associate appropriate behavioral measures with the therapy (daily introduction of at least  1,500 ml of fluids; do not retain urine; regulate intestinal transit; post-coital urination if the episodes occur after sexual intercourse).

Prophylactic treatment

Post-coital prophylaxis: once-administered antibiotic 2 hours after sexual intercourse. Due to the risk of induction of resistance, quinolones and beta-lactams should not be used.

Continuous prophylaxis: it should be evaluated case by case on the basis of the frequency of recurrences and the consequent disability. Duration of at least 6 months with risk of potentially serious undesirable effects (especially for nitrofurantoin) and induction of resistance; it does not reduce the risk of new recurrences of the suspension.

There is no evidence of efficacy in reducing the recurrence of blueberry derivatives.

Relapsing cystitis: prophylactic treatment

Chemotherapy

Dosage and duration

Comment

Nitrofurantoin

50-100 mg os x 1 / day

Post-coital forms: administer nitrofurantoin within 2 hours of sexual intercourse.

Non-post-coital forms: take nitrofurantoin in the evening.

If frequent and/or disabling recurrences: treatment duration of at least 6 months.

Evaluate who to treat on a case-by-case basis

Cotrimoxazole

(SMX 800 mg + TMP 160 mg)

1/2 tablet os x 1 / day

Post-coital forms: administer co-trimoxazole within 2 hours of sexual intercourse.

Non-post-coital forms: if frequent and/or disabling recurrences,

treatment duration of at least 6 months.

Evaluate who to treat on a case-by-case basis

Use co-trimoxazole only if% local

E.coli resistance  <20%

Simple or complicated acute pyelonephritis (PNA)

Recommended tests:  complete urinalysis, uroculture, complete urinary tract ultrasound within 24 hours (Grade C) + urgent urological examination.

Simple acute pyelonephritis

In the judgment of the general practitioner, the patient may be kept at home or hospitalized.  

Empirical treatment :

- 3 cephalosporins in  generation (Grade A): ceftriaxone IV / IM or cefotaxime (IV / IM);

- ciprofloxacin, oral, or iv levofloxacin (if the oral route is not practicable) if the patient has not been treated with a fluoroquinolone (Grade A) for the past 6 months. Switch to targeted oral therapy after obtaining the antibiogram. 

Duration of therapy, if favorable evolution: 10-14 days; for fluoroquinolones 7 days (Grade A).

Hospitalization: in case of sepsis or home management difficulties (hyperalgesic form, difficulty in carrying out investigations or treatment, precarious social conditions) or persistence of fever after 72 hours from the start of antibiotic therapy.   

Complicated acute pyelonephritis

Additional tests recommended: Urgent CT (Grade A).

Hospitalization: the situations that require hospitalization are the same as for simple pyelonephritis associated with the presence of serious complications (obstruction, tumor, abscess ...).

Empirical treatment:  same as simple PNA.

Switch to oral therapy after obtaining the antibiogram: same as simple PNA.

The total duration of treatment: 10-14 days; extension to 21 days or more in specific clinical situations (abscess, multidrug-resistant microorganism, chronic renal failure).

Simple or complicated acute pyelonephritis: empirical treatment

Chemotherapy

Dosage and duration

Ceftriaxone

1-2g x 1 / day iv, for 10-14 days

Treatment duration = or> 21 days in the presence of abscess, multidrug-resistant organism, chronic renal failure

Ciprofloxacin

500-750 mg os x 2 / day, for 7 days

400 mg iv x 2-3 / day, for 7 days

Levofloxacin

500 mg orally x 1 / day, for 7 days

500 mg orally x 1 / day, for 7 days

Cefixime

200 mg os x 2 / day for 10-14 days

Aztreonam

(if allergy and intolerance to other molecules)

1 g iv x 2-3 / day for 10-14 days

Gentamicin

3 mg / kg iv x 1 / day, for 1-3 days

In association

Notes

-  In men, complicated PNA should be treated like acute prostatitis.

- Need for control uroculture 48-72 hours from the start of treatment and 6 weeks from the end (risk of failure in case of obstruction, lithiasis ..).

- Need for urological management in case of obstruction and lithiasis.

Acute prostatitis

Recommended examinations: complete urinalysis, uroculture, and ultrasound of the urinary tract via the suprapubic route in urgency.

Empirical treatment: same as simple PNA 

Switch to oral targeted therapy after obtaining the antibiogram:

- systemic fluoroquinolone (ciprofloxacin, levofloxacin) or trimethoprim-sulfamethoxazole.

The patient must be sent for an urgent urological examination. The total duration of treatment: from 14 days (paucisymptomatic forms and sensitive bacteria) to 21 days in specific clinical situations (abscess, multidrug-resistant microorganism, inadequate empirical treatment  ..).

Acute prostatitis: other treatment after antibiogram

Chemotherapy

Dosage and duration

Comment

Cotrimoxazole

(SMX 800 mg + TMP 160 mg)

1 tablet os x 2-3 / day, for 14 days

Treatment duration = or> 21 days in the presence of complications, multi-drug resistant organism, age = or> 65 years

Notes

-  Antibiotic treatment must be started without waiting for the results of the antibiogram. 

- Due to the reduced tissue diffusion the use of amoxicillin is not recommended even if the microorganism is sensitive. Fluoroquinolones and co-trimoxazole are preferred for sensitive isolates. 

- In the presence of a prostate abscess, medical treatment alone is often sufficient.

- It is recommended to check the uroculture during treatment only if the evolution is unfavorable (persistence of fever after 72 hours despite correct antibiotic therapy).

- Uroculture is recommended 4-6 weeks after the end of therapy to highlight any chronic prostatitis and relapse.

- The PSA dosage should be performed no earlier than 6 months after the end of the infectious episode.

Urinary infections in pregnancy

Asymptomatic bacteriuria Treatment of asymptomatic bacteriuria is recommended in all pregnant women (Grade A).  

Targeted treatment based on the indications of the antibiogram:

- amoxicillin  (usable for the entire duration of pregnancy),

- amoxicillin-clavulanic acid ( except in the case of imminent birth ),

- cefixime ( usable for the entire duration of pregnancy ),

- nitrofurantoin  ( can be used throughout pregnancy ),

- trimethoprim-sulfamethoxazole (to be avoided in the 1st trimester of pregnancy ).

Total treatment duration: 5 days, except for nitrofurantoin 7 days. Short 3-day or single-dose treatments are not recommended.

Asymptomatic bacteriuria: targeted treatment after an antibiogram

Chemotherapy

Dosage and duration

  • Nitrofurantoin
  • 100 mg os x 3 / day, for 7 days

Possible throughout pregnancy

  • Amoxicillin
  • 1 g os x 3 / day, for 5 days

Possible throughout pregnancy

Amoxicillin-clavulanic acid

1 g os x 3 / day, for 5 days

Except in case of imminent birth

Cefixime

200 mg os x 2 / day, for 5 days

Possible throughout pregnancy

Cotrimoxazole

(SMX 800 mg + TMP 160 mg):

1 tablet os x 2 / day, for 5 days

To be avoided in the 1st quarter

Notes

-  Definition of asymptomatic bacteriuria: asymptomatic patient + 2 positive cultures with the same isolate (cut off bacteriuria> 10 5  CFU / ml, leukocyte does not enter the definition).

- Screening for symptomatic bacteriuria: dipstick for leukocyte esterase and nitrites once a month starting from the 4th month; in case of positivity, carry out uroculture.

- Systematic screening with uroculture in high-risk pregnant women (underlying organic or functional uropathy, history of acute relapsing cystitis, functional changes in urination, diabetes, vaginal infection) of urinary infection (Grade A). Uroculture must be repeated monthly.

- It is necessary to repeat uroculture after 8-10 days from the end of treatment and therefore once a month. 

Acute cystitis Recommended examination: systematic uroculture. Empirical treatment (to be started without waiting for the results of the antibiogram ): - cefixime or nitrofurantoin (Grade B) Targeted treatment after obtaining the antibiogram: - amoxicillin - amoxicillin-clavulanic acid ( except in case of imminent birth ), - cefixime   - nitrofurantoin    - trimethoprim-sulfamethoxazole (to be avoided in the 1st trimester of pregnancy ). The total duration of treatment: at least 5 days, except for nitrofurantoin: at least 7 days.    

Acute cystitis: empirical treatment

Chemotherapy

Dosage and duration

Cefixime

200 mg os x 2 / day, for = or> 5 days

Possible throughout pregnancy

Nitrofurantoin

100 mg os x 3 / day, for = or> 7 days

1 g os x 3 / day, for = or> 5 days

Possible throughout pregnancy

Amoxicillin-clavulanic acid

(except for the risk of imminent birth)

1 g os x 3 / day, for = or> 5 days

Except in case of imminent birth

Cotrimoxazole

(SMX 800 mg + TMP 160 mg)

1 tablet os x 2 / day, for = or> 5 days

To be avoided in the 1st quarter

Acute pyelonephritis 

Hospitalization recommended.  

Recommended examination: uroculture, ultrasound of the urinary tract, and evaluation of the fetal situation, in urgency.

Empirical treatment:

- 3 cephalosporins in generation parenteral: ceftriaxone IV / IM or IV cefotaxime (Grade A).If the severe form (obstructive syndrome, sepsis, septic shock ...) to add an aminoglycoside (gentamicin) for 1-3 days.   

Switch to oral therapy after obtaining the antibiogram:

- amoxicillin

- amoxicillin-clavulanic acid ( except in case of imminent birth ),

- cefixime  

- trimethoprim-sulfamethoxazole ( avoid in the 1st trimester of pregnancy ).

The total duration of treatment: at least 14 days.

 Acute pyelonephritis: empirical treatment

Ceftriaxone

Posology and total duration of treatment  of "Simple or complicated acute pyelonephritis outside pregnancy"

Gentamicin

Acute pyelonephritis: other possible treatment after an antibiogram

Amoxicillin

1 g os x 3 / day, total duration of treatment 14 days

Amoxicillin-clavulanic acid

(except for the risk of imminent birth)

1 g os x 3 / day, total duration of treatment 14 days

Cefixime

200 mg os x 2 / day, total duration of treatment 14 days

Cotrimoxazole

(to be avoided as a precaution in the 1st trimester)

1 tablet os x 2 / day, total duration of treatment 14 days

Notes

-  Hospitalization is recommended for at least 48-72 hours to also define the fetal situation. 

- Criteria that allow you to continue the treatment at home:

Management period  = or> 24 weeks.

Well-tolerated oral therapy (no nausea or vomiting).

No associated co-morbidities.

Not no signs of gravity.

Normal obstetric examination

Favorable socioeconomic conditions for oral treatment.

In some cases (allergy, intolerance ...) aztreonam or an aminoglycoside, or a fluoroquinolone can be used (after infectious consultation).  

- Switch to oral therapy can be done after 48 hours of apyrexia.

- Maternal and fetal clinical surveillance is essential. 

- It is advisable to repeat the uroculture after 48 hours from the beginning of the treatment, 8-10 days from the end of the treatment, and therefore once a month.

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