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.