Urinary Tract Infection (UTI) and Cystitis (Bladder Infection) in Females Guidelines

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.

References
  1. Liu P, Hamilton KW, O'Donnnell JA. Urinary Tract Infection. Cunha CB. Schlosberg Clinical Infectious Disease. Third. Oxford University Press; 2022. 423-429.
  2. [Guideline] Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar. 52(5):e103-20. [QxMD MEDLINE Link]. [Full Text].
  3. [Guideline] Wagenlehner FM, Schmiemann G, Hoyme U, Fünfstück R, Hummers-Pradier E, Kaase M, et al. [National S3 guideline on uncomplicated urinary tract infection: recommendations for treatment and management of uncomplicated community-acquired bacterial urinary tract infections in adult patients]. Urologe A. 2011 Feb. 50(2):153-69. [QxMD MEDLINE Link]. [Full Text].
  4. Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008 Mar. 22(1):73-87, vi. [QxMD MEDLINE Link].
  5. Little P, Turner S, Rumsby K, Warner G, Moore M, Lowes JA, et al. Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study. Health Technol Assess. 2009 Mar. 13(19):iii-iv, ix-xi, 1-73. [QxMD MEDLINE Link].
  6. Lane DR, Takhar SS. Diagnosis and management of urinary tract infection and pyelonephritis. Emerg Med Clin North Am. 2011 Aug. 29(3):539-52. [QxMD MEDLINE Link].
  7. Czaja CA, Stamm WE, Stapleton AE, et al. Prospective cohort study of microbial and inflammatory events immediately preceding Escherichia coli recurrent urinary tract infection in women. J Infect Dis. 2009 Aug 15. 200(4):528-36. [QxMD MEDLINE Link].
  8. Adeghate J, Juhász E, Pongrácz J, Rimanóczy É, Kristóf K. Does Staphylococcus Saprophyticus Cause Acute Cystitis only in Young Females, or is there more to the Story? A One-Year Comprehensive Study Done in Budapest, Hungary. Acta Microbiol Immunol Hung. 2016 Mar. 63 (1):57-67. [QxMD MEDLINE Link].
  9. Kanj SS, Kanafani ZA. Current concepts in antimicrobial therapy against resistant gram-negative organisms: extended-spectrum beta-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa. Mayo Clin Proc. 2011 Mar. 86(3):250-9. [QxMD MEDLINE Link]. [Full Text].
  10. [Guideline] Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010 Mar 1. 50(5):625-63. [QxMD MEDLINE Link]. [Full Text].
  11. Tiemstra JD, Chico PD, Pela E. Genitourinary infections after a routine pelvic exam. J Am Board Fam Med. 2011 May-Jun. 24(3):296-303. [QxMD MEDLINE Link].
  12. Hsiao CJ, Cherry DK, Beatty PC, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2007 summary. Natl Health Stat Report. 2010 Nov 3. 1-32. [QxMD MEDLINE Link].
  13. Naber KG, Schito G, Botto H, Palou J, Mazzei T. Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): implications for empiric therapy. Eur Urol. 2008 Nov. 54(5):1164-75. [QxMD MEDLINE Link].
  14. Little P, Merriman R, Turner S, Rumsby K, Warner G, Lowes JA, et al. Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study. BMJ. 2010 Feb 5. 340:b5633. [QxMD MEDLINE Link]. [Full Text].
  15. Molander U, Arvidsson L, Milsom I, Sandberg T. A longitudinal cohort study of elderly women with urinary tract infections. Maturitas. 2000 Feb 15. 34(2):127-31. [QxMD MEDLINE Link].
  16. Johnson L, Sabel A, Burman WJ, Everhart RM, Rome M, MacKenzie TD, et al. Emergence of fluoroquinolone resistance in outpatient urinary Escherichia coli isolates. Am J Med. 2008 Oct. 121(10):876-84. [QxMD MEDLINE Link].
  17. [Guideline] American College of Obstetricians and Gynecologists (ACOG). 2008. Treatment of urinary tract infections in nonpregnant women. Available at https://guideline.gov/content.aspx?id=12628. Accessed: September 22, 2010.
  18. Falcone M, Suardi LR, Tiseo G, et al. Superinfections caused by carbapenem-resistant Enterobacterales in hospitalized patients with COVID-19: a multicentre observational study from Italy (CREVID Study). JAC Antimicrob Resist. 2022 Jun. 4 (3):dlac064. [QxMD MEDLINE Link].
  19. Corcione S, Montrucchio G, Shbaklo N, et al. First Cases of Candida auris in a Referral Intensive Care Unit in Piedmont Region, Italy. Microorganisms. 2022 Jul 27. 10 (8):[QxMD MEDLINE Link].
  20. Taylor RA, Moore CL, Cheung KH, Brandt C. Predicting urinary tract infections in the emergency department with machine learning. PLoS One. 2018. 13 (3):e0194085. [QxMD MEDLINE Link].
  21. Barclay L. Urinary Tract Infection: 3 Questions Aid Diagnosis in Women. Medscape Medical News. Available at https://www.medscape.com/viewarticle/810667. Accessed: September 16, 2013.
  22. Knottnerus BJ, Geerlings SE, Moll van Charante EP, Ter Riet G. Toward a simple diagnostic index for acute uncomplicated urinary tract infections. Ann Fam Med. 2013 Sep-Oct. 11(5):442-51. [QxMD MEDLINE Link]. [Full Text].
  23. Schaeffer AJ, Schaeffer EM. Infections of the Urinary Tract. In: McDougal WS, Wein AJ, Kavoussi LR, et al, eds. Campbell-Walsh Urology. 10th Ed. Philadelphia, PA: Elsevier Saunders; 2012. 46-55.
  24. Lifshitz E, Kramer L. Outpatient urine culture: does collection technique matter?. Arch Intern Med. 2000 Sep 11. 160(16):2537-40. [QxMD MEDLINE Link].
  25. Propp DA, Weber D, Ciesla ML. Reliability of a urine dipstick in emergency department patients. Ann Emerg Med. 1989 May. 18(5):560-3. [QxMD MEDLINE Link].
  26. Mehnert-Kay SA. Diagnosis and Management of Uncomplicated Urinary Tract Infections. American Family Physician. August 1, 2005. 27/No.3:1-9. [Full Text].
  27. [Guideline] Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010 Apr. 31(4):319-26. [QxMD MEDLINE Link]. [Full Text].
  28. Kauffman CA, Fisher JF, Sobel JD, Newman CA. Candida urinary tract infections--diagnosis. Clin Infect Dis. 2011 May. 52 Suppl 6:S452-6. [QxMD MEDLINE Link].
  29. Falagas ME, Kotsantis IK, Vouloumanou EK, Rafailidis PI. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta-analysis of randomized controlled trials. J Infect. 2009 Feb. 58(2):91-102. [QxMD MEDLINE Link].
  30. Foxman B. The epidemiology of urinary tract infection. Nat Rev Urol. 2010 Dec. 7(12):653-60. [QxMD MEDLINE Link].
  31. Little P, Moore MV, Turner S, Rumsby K, Warner G, Lowes JA, et al. Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. BMJ. 2010 Feb 5. 340:c199. [QxMD MEDLINE Link]. [Full Text].
  32. Lavigne JP, Bruyère F, Bernard L, Combescure C, Ronco E, Lanotte P, et al. Resistance and virulence potential of uropathogenic Escherichia coli strains isolated from patients hospitalized in urology departments: a French prospective multicentre study. J Med Microbiol. 2016 Jun. 65 (6):530-7. [QxMD MEDLINE Link].
  33. Christiaens TC, De Meyere M, Verschraegen G, Peersman W, Heytens S, De Maeseneer JM. Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. Br J Gen Pract. 2002 Sep. 52(482):729-34. [QxMD MEDLINE Link]. [Full Text].
  34. Bleidorn J, Gágyor I, Kochen MM, Wegscheider K, Hummers-Pradier E. Symptomatic treatment (ibuprofen) or antibiotics (ciprofloxacin) for uncomplicated urinary tract infection?--results of a randomized controlled pilot trial. BMC Med. 2010 May 26. 8:30. [QxMD MEDLINE Link]. [Full Text].
  35. Grigoryan L, Zoorob R, Wang H, Trautner BW. Low Concordance With Guidelines for Treatment of Acute Cystitis in Primary Care. Open Forum Infect Dis. 2015 Dec. 2 (4):ofv159. [QxMD MEDLINE Link].
  36. Sigler M, Leal JE, Bliven K, Cogdill B, Thompson A. Assessment of appropriate antibiotic prescribing for urinary tract infections in an internal medicine clinic. South Med J. 2015 May. 108 (5):300-4. [QxMD MEDLINE Link].
  37. Olson RP, Harrell LJ, Kaye KS. Antibiotic resistance in urinary isolates of Escherichia coli from college women with urinary tract infections. Antimicrob Agents Chemother. 2009 Mar. 53(3):1285-6. [QxMD MEDLINE Link]. [Full Text].
  38. McKinnell JA, Stollenwerk NS, Jung CW, Miller LG. Nitrofurantoin compares favorably to recommended agents as empirical treatment of uncomplicated urinary tract infections in a decision and cost analysis. Mayo Clin Proc. 2011 Jun. 86(6):480-8. [QxMD MEDLINE Link]. [Full Text].
  39. Falagas ME, Vouloumanou EK, Togias AG, Karadima M, Kapaskelis AM, Rafailidis PI, et al. Fosfomycin versus other antibiotics for the treatment of cystitis: a meta-analysis of randomized controlled trials. J Antimicrob Chemother. 2010 Sep. 65(9):1862-77. [QxMD MEDLINE Link]. [Full Text].
  40. Xin H, Rosario-Colon JA, Eberle K. Novel Intravenous Immunoglobulin Therapy for the Prevention and Treatment of Candida auris and Candida albicans Disseminated Candidiasis. mSphere. 2023 Jan 23. e0058422. [QxMD MEDLINE Link].
  41. [Guideline] Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1. 40(5):643-54. [QxMD MEDLINE Link]. [Full Text].
  42. Dalal S, Nicolle L, Marrs CF, Zhang L, Harding G, Foxman B. Long-term Escherichia coli asymptomatic bacteriuria among women with diabetes mellitus. Clin Infect Dis. 2009 Aug 15. 49(4):491-7. [QxMD MEDLINE Link]. [Full Text].
  43. Beerepoot MA, ter Riet G, Nys S, et al. Cranberries vs antibiotics to prevent urinary tract infections: a randomized double-blind noninferiority trial in premenopausal women. Arch Intern Med. 2011 Jul 25. 171(14):1270-8. [QxMD MEDLINE Link].
  44. Jepson RG, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2008 Jan 23. CD001321. [QxMD MEDLINE Link].
  45. Tempera G, Corsello S, Genovese C, Caruso FE, Nicolosi D. Inhibitory activity of cranberry extract on the bacterial adhesiveness in the urine of women: an ex-vivo study. Int J Immunopathol Pharmacol. 2010 Apr-Jun. 23(2):611-8. [QxMD MEDLINE Link].
  46. Frellick M. Drinking More Water Reduces Repeat Urinary Tract Infections. Medscape Medical News. Available at https://www.medscape.com/viewarticle/886775. October 9, 2017; Accessed: October 10, 2017.
  47. De Vita D, Giordano S. Effectiveness of intravesical hyaluronic acid/chondroitin sulfate in recurrent bacterial cystitis: a randomized study. Int Urogynecol J. 2012 Dec. 23(12):1707-13. [QxMD MEDLINE Link].
  48. [Guideline] Anger J, Lee U, Ackerman AL, Chou R, Chughtai B, Clemens JQ, et al. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. J Urol. 2019 May 1. 101097JU0000000000000296. [QxMD MEDLINE Link]. [Full Text].
  49. van der Starre WE, van Nieuwkoop C, Paltansing S, et al. Risk factors for fluoroquinolone-resistant Escherichia coli in adults with community-onset febrile urinary tract infection. J Antimicrob Chemother. 2011 Mar. 66(3):650-6. [QxMD MEDLINE Link].
  50. Cloutier DJ, Miller LG, Komirenko AS, Cebrik DS, Krause KM, Keepers TR, et al. Plazomicin Versus Meropenem for the Treatment of Complicated Urinary Tract Infection and Acute Pyelonephritis: Results of the EPIC Study. Presented at the 27th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), Vienna, Austria, April 22-25, 2017.
  51. Cunha BA. Prophylaxis for recurrent urinary tract infections: nitrofurantoin, not trimethoprim-sulfamethoxazole or cranberry juice. Arch Intern Med. 2012 Jan 9. 172(1):82; author reply 82-3. [QxMD MEDLINE Link].
  52. Cunha BA, Schoch PE, Hage JR. Nitrofurantoin: preferred empiric therapy for community-acquired lower urinary tract infections. Mayo Clin Proc. 2011 Dec. 86(12):1243-4; author reply 1244. [QxMD MEDLINE Link]. [Full Text].
  53. Fischer HD, Juurlink DN, Mamdani MM, Kopp A, Laupacis A. Hemorrhage during warfarin therapy associated with cotrimoxazole and other urinary tract anti-infective agents: a population-based study. Arch Intern Med. 2010 Apr 12. 170(7):617-21. [QxMD MEDLINE Link].
  54. Hand L. Urinary Infections: Report Offers Long-Needed Clarity. Medscape [serial online]. Available at https://www.medscape.com/viewarticle/814305. Accessed: November 18, 2013.
  55. Hooton TM, Roberts PL, Cox ME, Stapleton AE. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med. 2013 Nov 14. 369(20):1883-91. [QxMD MEDLINE Link].
  56. Leydon GM, Turner S, Smith H, Little P. Women's views about management and cause of urinary tract infection: qualitative interview study. BMJ. 2010 Feb 5. 340:c279. [QxMD MEDLINE Link]. [Full Text].
  57. Pinson AG, Philbrick JT, Lindbeck GH, Schorling JB. ED management of acute pyelonephritis in women: a cohort study. Am J Emerg Med. 1994 May. 12(3):271-8. [QxMD MEDLINE Link].
  58. Turner D, Little P, Raftery J, Turner S, Smith H, Rumsby K, et al. Cost effectiveness of management strategies for urinary tract infections: results from randomised controlled trial. BMJ. 2010 Feb 5. 340:c346. [QxMD MEDLINE Link]. [Full Text].
Media Gallery Nonobstructing distal left ureteral calculus 2 X 1 X 2 cm. Multiple abscesses, upper pole of left kidney. Bilateral hydronephrosis.

Plain radiograph in a 63-year-old patient with poorly controlled type 2 diabetes mellitus shows emphysematous cystitis.

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