Guidelines for antimicrobial treatment of uncomplicated acute bacterial
cystitis and acute pyelonephritis in women.
SOURCE(S):
Clin Infect Dis 1999 Oct;29(4):745-58 [82 references]
Each recommendation includes a ranking for the strength and the quality of
evidence supporting it. Definitions of the levels of evidence (I-III) and
grades of recommendation (A-E) are repeated at the end of the Major
Recommendations field.
Acute Uncomplicated Bacterial Cystitis
In otherwise healthy adult nonpregnant women with acute uncomplicated
bacterial cystitis, single-dose therapy is generally less effective than the
same antimicrobial used for longer durations (AI). However, most
antimicrobials given for 3 days are as effective as the same antimicrobial
given for a longer duration (AI).
Trimethoprim-sulfamethoxazole for 3 days should be considered the current
standard therapy (AI). Trimethoprim alone (AII) and ofloxacin (AI) are
equivalent to trimethoprim-sulfamethoxazole; other fluoroquinolones, such as
norfloxacin, ciprofloxacin, and fleroxacin, are probably of similar
effectiveness (AII). Fluoroquinolones are more expensive than
trimethoprim-sulfamethoxazole and trimethoprim, and, to postpone emergence
of resistance to these drugs, we do not recommend them as initial empirical
therapy except in communities with high rates of resistance (i.e., >10%–20%)
to trimethoprim-sulfamethoxazole or trimethoprim among uropathogens. When
given for 3 days, beta-lactams as a group are less effective than the
foregoing drugs (EI). Nitrofurantoin and fosfomycin may become more useful
as resistance to trimethoprim-sulfamethoxazole and trimethoprim increase
(BI).
Acute pyelonephritis. The few properly designed trials for management of
acute pyelonephritis are several years old, precluding recommendations
firmly based on recent evidence. For young nonpregnant women with normal
urinary tracts presenting with an episode of acute pyelonephritis, 14 days
of antimicrobial therapy is appropriate (AI); courses of highly active
agents as short as 7 days may be sufficient for mild or moderate cases (BI).
Mild cases can be managed with oral medications (AII), and we recommend an
oral fluoroquinolone (AII) or, if the organism is known to be susceptible,
trimethoprim-sulfamethoxazole (BII). If a gram-positive bacterium is the
likely causative organism, amoxicillin or amoxicillin/clavulanic acid may be
used alone (BIII). Patients with more severe cases of acute pyelonephritis
should be hospitalized (AII) and treated with a parenteral fluoroquinolone,
an aminoglycoside with or without ampicillin, or an extended-spectrum
cephalosporin with or without an aminoglycoside (BIII); if gram-positive
cocci are causative, we recommend ampicillin/sulbactam with or without an
aminoglycoside as therapy (BIII). With improvement, the patient’s regimen
can be changed to an oral antimicrobial to which the organism is susceptible
to complete the course of therapy (BIII).
Definitions of Strength of Recommendation and Quality of Evidence Ratings:
Quality of evidence:
                               I.            Evidence from at least one
properly randomized, controlled trial
                            II.            Evidence from at least one
well-designed clinical trial without randomization, from cohort or
case-control analytic studies (preferably from more than one center), from
multiple time-series studies, or from dramatic results of uncontrolled
experiments
                         III.            Evidence from opinions of respected
authorities based on clinical experience, descriptive studies, or reports of
expert committees
Strength of recommendation:
A.   Good evidence to support a recommendation for use
B.   Moderate evidence to support a recommendation for use
C.   Poor evidence to support a recommendation
D.  Moderate evidence to support a recommendation against use
E.   Good evidence to support a recommendation against use
COMMITTEE:
Infectious Diseases Society of America (IDSA) Practice Guidelines Committee
GROUP COMPOSITION:
Authors: John W. Warren, Elias Abrutyn, J. Richard Hebel, James R. Johnson,
Anthony J. Schaeffer, and Walter E. Stamm.



Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.