Escolar Documentos
Profissional Documentos
Cultura Documentos
Ambulatory
Clinical Background
For more information Clinical Problem Antibiotic treatment should be prescribed only
734-936-9771
and Management Issues for as long as necessary to be effective.
Recurrent UTIs may be managed better by self-
Incidence initiated therapy or prophylaxis than by
Regents of the continuing to treat each case emergently. This
University of Michigan
Urinary tract infections (UTI) are estimated to guideline provides an approach to uncomplicated
account for over 7 million office visits per year, UTI that results in good clinical outcomes and
These guidelines should not at a cost of over $1 billion. Up to 40% of utilizes clinical care resources appropriately.
be construed as including all women will develop UTI at least once during
proper methods of care or
excluding other acceptable their lives, and a significant number of these
methods of care reasonably women will have recurrent urinary tract Rationale for Recommendations
directed to obtaining the
same results. The ultimate
infections.
judgment regarding any The rationale for recommendations addresses:
specific clinical procedure Cost-Effective Strategy
or treatment must be made Risk factors
by the physician in light of
Establishing a cost-effective strategy for the Complicating factors
the circumstances presented
by the patient. diagnosis and treatment of UTI is important Uncomplicated UTI
because of its high incidence. Laboratory tests Recurrent UTIs
should be ordered only when the results are Asymptomatic bacteriuria
likely to alter the process or outcome of care. Acute uncomplicated pyelonephritis
UTI in pregnancy
(Continued on page 3)
1
Figure 1. Diagnosis and Management of UTI in Adult Non-Pregnant Women
Adult non-pregnant woman
with UTI symptoms
telephones office
Eligible for prescription by phone?
(See nursing Protocol)
Previous history of Similar symptoms to prior UTIs Empiric treatment
Yes
uncomplicated UTIs? Lack of vaginitis symptoms (See Table 3)
No complicating factors/pyelo
No symptoms (see Table 2)
No
Asymptomatic after 3
Schedule office visit No
days?
Yes
No
Consider:
Urinalysis microscopic
Negative Pelvic exam
dipstick results
Urine culture
Positive
Complicating conditions:
Complicating factors? (Table 2) See complicating factors section
UTI uncomplicated? No Recurrent UTIs? (>3/year) See recurrent UTI section
Pyelo symptoms? See pyelonephritis section
Pregnancy? See pregnancy section
Yes
Patients presenting with typical lower tract symptoms Before transurethral resection of prostate or other
(dysuria, frequency, urgency, etc.) with associated flank urologic procedure for which mucosal bleeding is
pain, abdominal pain, nausea, vomiting, fever or chills anticipated. Post-operative complications, including
should be suspected of having pyelonephritis. In fact, a bacteremia, are reduced by treating bacteriuria prior to
significant percentage (up to 20% in some cases) of patients urologic procedures.
who present with seemingly uncomplicated UTI without Treatment of asymptomatic bacteriuria in women with
typical pyelonephritis symptoms can be shown by diabetes does not reduce complications. Therefore diabetes
bacteriologic localization studies to have involvement of is not an indication for screening or treatment of
the kidney. Many women with pyelonephritis can be safely asymptomatic bacteriuria.
managed on an outpatient basis with oral antibiotics.
Hospital admission with intravenous antibiotics is indicated
for acutely toxic patients, pregnant or immunocompromised UTI in Pregnancy
women, women unable to take in oral fluids, or in those
where compliance is a significant issue. UTI is the most frequent medical complication of
pregnancy. Physiologic changes, both hormonal and
In patients suspected of having pyelonephritis a urine mechanical, predispose the bacteriuric woman to an
culture and susceptibility should be performed. Treatment increased risk for developing acute pyelonephritis, preterm
options include 7 days of oral ciprofloxacin 500 mg po birth, and unexplained perinatal death. Factors contributing
BID or oral Bactrim for 14 days after Ceftriaxone 1 gm to increased risk of disease include dilation of the ureters
IM/IV or 10-14 days of a beta- lactam. Adequate response and renal pelvises, increased urinary pH, and glycosuria
to therapy is defined as clear improvement in clinical promoting bacterial growth and decrease in the ureteric
condition over 48-72 hours. (It does not necessarily include muscle tone.
becoming afebrile.) Follow-up urinalysis and cultures
should be considered 1-2 weeks after completion of Asymptomatic bacteria (ASB). ASB occurs in 4-7% of
therapy, however routine structural evaluation is rarely pregnant patients. Unlike nonpregnant women with ASB,
indicated. in whom intervention is not recommended, pregnant
patients with ASB will go on to develop pyelonephritis in
up to 40% of cases if left untreated. Pyelonephritis in the
Asymptomatic Bacteriuria (ASB) pregnant patient leads to septicemia in 10-20% of cases and
ARDS in 2%. Screening for asymptomatic bacteriuria is
Diagnosis. Asymptomatic bacteriuria is the presence of recommended for pregnant women at the first prenatal visit.
"significant" numbers of bacteria in the urine without the Urine culture is an appropriate screening tool. Clean catch
presence of symptoms. The presence of one organism per urine analysis is recognized as an appropriate screening tool
high-powered field in a clean-catch, midstream, unspun by the American College of Obstetricians and
urine sample represents significant bacteriuria (equivalent Gynecologists.
to >105 CFU/ml).
Treatment of ASB can be accomplished with a variety of
Patients with chronic indwelling catheters are at particular FDA category B drugs (see definitions below) including
risk for developing bacteriuria. The risk of UTI can be amoxicillin, cephalosporins, nitrofurantoin and fosfomycin
decreased by using catheters only when necessary, insertion Fluoroquinolones should generally not be used during
of the catheter under aseptic technique, use of a closed pregnancy (FDA Category C). A seven day course for
The literature search for this update began with the results Team Member Company Relationship
of the literature search performed for the earlier version of
this guideline (1/1/91-6/30/98; 7/1/98 to 8/31/04. However, Catherine M. Bettcher, MD (None)
instead of beginning the search with literature in 2004, the Carol E. Chenoweth, MD (None)
guideline team accepted the search strategy and results for Steven E. Gradwohl, MD (None)
the search performed through 4/30/07 for the ACOG R. Van Harrison, PhD (None)
Practice Bulletin No. 91, Treatment of urinary tract Lauren B. Zoschnick, MD (None)
infections in nonpregnant women (see Related National
Guidelines).
The additional search for the update of this guideline was Review and Endorsement
conducted prospectively on Medline using the major
keywords of: urinary tract infections; guidelines, Drafts of this guideline were reviewed in clinical
controlled trials, and cohort studies; published from 1/1/07 conferences and by distribution for comment within
to 4/30/10; humans, adult women. Specific searches were departments and divisions of the University of Michigan
performed for: predictive value of tests, diagnosis (other Medical School to which the content is most relevant:
than predictive value of tests), treatment, uncomplicated Family Medicine, General Medicine, General Obstetrics &
UTI treatment, pregnancy, postmenopausal women Gynecology, and Infectious Diseases. The Executive
treatment, recurrent UTI, self initiated therapy, group B Committee for Clinical Affairs of the University of