1

(Evidence-based treatment of UTI)

2

(Evidence-based clinical practice guideline)

2002)

3

(infection)

-

-

-

-

-

-

-

-

-

-

-

4

(urinary tract infectionUTI)

(inflammatory response)

Anthony J Schaeffer : Infections of the Urinary Tract in Campbells Urology, 7th ed, 1998

5

Acute cystitis in women

E-coli, staphylococcus saprophyticus, proteus mirabilis, klebsiella pneumoniae

Sexual history, personal hygeine. use of diaphragm, pregnancy, symptoms > 7 days

Acute pyelonephritis in women

E-coli, Proteus mirabilis, staphylococcus saprophyticus, klebsiella pneumoniae

Sexual history, pregnancy,DM, foley catheter, children, age > 65 y/o, neurogenic bladder, renal stone,

UTI in man

E-coli, Proteus, Klebsiela, Pseudomonas, enterococcus, staphylococcus

Sexual history,BPH, DM, foley catheter, children, age > 65 y/o, neurogenic bladder, renal stone,

6

(bacteriuria)

()

(pyuria)

(white blood cell)

(urinary tract infection)

Anthony J Schaeffer : Infections of the Urinary Tract in Campbells Urology, 7th ed, 1998

7

Urine culture and bacteriuria

Urine culture(cfu/ml)

Asymptomatic bacteriuria >= 100,000

Pyelonephritis >=10,000

Cystitis >=1,000

8

()

9

()

uncomplicated UTI

cystitis

urethritis

complicated UTI

acute pyelonephritis

chronic pyelonephritis

renal abscess or carbuncle

Urinary tract infection with host structural or immune abnormality.

Male with urinary tract infection

reinfection (another episode)

bacterial persistence (same bacteria, not eradicated)

10

trimethoprim-sulfamethoxazole (TMP-SMX, Baktar)

cephalosporins

fluoroquinolones

aminoglycosides

nitrofurantoin

aminopenicillins

aztreonam

Anthony J Schaeffer : Infections of the Urinary Tract in Campbells Urology, 7th ed, 1998

11

Evidence-Based Clinical Practice Guideline

12

?

David L. Sackett et al. (Ontario, Canada, 2000)

:

Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise and patient values.-

,

,.

13

, (),

.

14

Systematic review of randomized control studies

Single randomized control study

Systematic review of observational studies

Single observational study

Physiologic studies

Unsystematic clinical observationslow

high

Hierarchy of evidence

Guyatt et al. 2002

( less bias )

( more bias )

15

? (systematic review)

,

, ,, .

Systematic reviews are scientific investigations in themselves, with pre-planned methods and an assembly of original studies as their subjects. They synthesize the results of multiple primary investigations by using strategies that limit bias and random error.

Mulrow & Cook, in Systematic Reviews - synthesis of best evidence for health care decisions, 1998, American College of Physicians.

16

National Guideline Clearinghouse

National Guideline Clearinghouse

Guideline

?

National Guideline Clearinghouse (www.guideline.gov)

http://www.guideline.gov/

17

National Guideline Clearinghouse

Evidence-based clinical practice guidelines for patients 6 years of age or less with first time acute urinary tract infection.

( Childrens Hospital Medical Center, Cincinnati ,1999)

Guidelines for Antimicrobial Treatment of Uncomplicated Acute Bacterial Cystitis and Acute Pyelonephritis in Women

(Infectious Disease Society of America, IDSA 1999)

Use of antibiotics in adults(Singapore Ministry of Health, MOH, 2000)

!

18

(presumed UTI)

Presumed UTI = UTI symptoms + abnormal urinalysis (pyuria)

abnormal urinalysis

(nitrite)

esterase

(microscopic exam)

19

(definite UTI)

+

Definite UTI=presumed UTI

+ positive urine cultutre

(single

organism)

suprapubic aspirate (SPA) >= 1,000 cfu/ml

catheter specimen (Cath)>=10,000 cfu/ml

clean voided specimen ( CVS)>=100,000 cfu/ml

20

(Uncomplicated UTI)

,

21

(Complicated UTI)

(VU reflux in children)

(neurogenic bladder, BPH, stone, stricture or tumor)

22

(uncomplicated acute bacterial cystitis)

3

(dysuria)

(frequency)

(urgency)

>1,000 cfu/ml

23

(acute pyelonephritis)

(fever), / (flank pain)

3 (dysuria)(frequency)

(urgency)

( )

24

Recommended treatment for uncomplicated and complicated UTI

A( Ia Ib)

(literature of good quality) (randomised, controlled trial)

B( IIa IIbIII)

C( IV)

GPP (Good practice point)

(guideline development group)

Ia (randomised, controlled trials)(meta-analysis)

Ib (randomised, controlled trial)

IIa (well-designed controlled study without

randomisation)IIb

(well-designed quasi-experimental study)III (non-

experimental descriptive studies)

IV

27

(asymptomatic bacteriuria)

(A, Ib)

-

28

(acute cystitis in women)

,

(A, Ia)

:

trimethoprim/sulfamethoxazol 160/800 mg BID for 3 days (A, Ib)

fluoroquinolones (ciprofloxacin 250mgofloxacin 200mgnorfloxacin 400mg)TID

for 3 days (A, Ib)

first or second generation of cephalosporins for 7 days (B, II)

nitrofurantointrimethoprim for 7 days (B, II)

29

(recurrent cystitis in women)

trimethoprim/sulfamethoxazol 40/200 mg

nitrofurantoin 50 mg

cephalexin 100 mg

trimethoprim 100 mg

(B, IIa)

30

() (acute pyelonephritis in women)

cephalosporins

- cephalexin 250 mg qidcefaroxil 500 mg bidcefuroxime 125 mg bid

fluoroquinolones- ciprofloxacin 500 mg bidofloxacin 400 mg bidnorfloxacin 400 mg bid

amoxicillin-clavulanic acid 375 mg tid

trimethoprim/sulfamethoxazol 160/800 mg bid

(14) (B, III)

31

() (acute pyelonephritis in women)

()!

:

- cephalosporins- fluoroquinolones- ampicillins plus aminoglycosides- cephalosporins plus aminoglycosides (B,III)

cephalosporins plus aminoglycosides cephazolin 500 mg q8h or cefuroxime 750 mg q8h

+ gentamicin 1 mg/kg q8h

24

(14)

(B, III)

32

(UTI in pregnancy)

(asymptomatic bacteriuria)

(A, Ia)

(acute cystitis) cephalosporins

nitrofurantointrimethoprim/sulfamethoxazole

(7)

(B, III)

(acute pyelonephritis in pregnancy) cephalosporins

(ceftriaxone 1 g)

(14)

(B, III)

33

(acute cystitis in adult men)

/

(STD)

trimethoprim/sulfamethoxazol 160/800 mg bid

fluoroquinolones

ciprofloxacin 250mgofloxacin 200mg norfloxacin 400mg bid

~ (7~14)

(C, IV)

34

(acute prostatitis)

,,

(blood PSA,

urine or prostate secretion culture)

trimethoprim/sulfamethoxazol 160/800 mg bid

fluoroquinolones

ciprofloxacin 250mgofloxacin 200mg norfloxacin 400mgbid

(28)

(B, III)

35

(chronic bacterial prostatitis)

,

, ,

,

trimethoprim/sulfamethoxazol 160/800 mg bid

fluoroquinolones

ciprofloxacin 250mgofloxacin 200mg norfloxacin 400mgbid

(84)

(B, III)

36

(chronic abacterial prostatitis)

doxycyclin 100 mg bid

erythromycin 250mg qid

(14)

(C, IV)

37

(complicated UTI)

fluoroquinolones

trimethoprim/sulfamethoxazol

(14) (A, Ib)

cephalosporins

(14) (C, IV)

38

(complicated UTI)

cephalosporinsfluoroquinolones

-lactam/

-lactamase inhibitor

(14

)

(C, IV)

ampicillinaminoglycoside

(14 )

(C, IV)

39

(complicated UTI)

(catheter-related UTI, bacteriuria 10~15%, UTI 3~5% per day of catheterization)

()

(14 ~ 28)

(UTI in renal failure) aminoglycoside()

(14 ~ 42)

40

2002

41

19976-

40

34.6

12.0

10.5

7.5

5.4

---

5.1

3.9

3.1

1.8

1.8

(,1998)

42

43

(2002)

(1993)

( Mainous1998)

44

45

()

2002

12

46

()

National Guideline Clearinghouse (www.guideline.gov)

1999

2000

http://www.guideline.gov/

47

WHO

48

/

(over use)

(under use)

1.2.3.1.

-*

1.

2.

*(clinical practice guidelines)

50

A. 200,000B. 2,572,065C. a. 11,008 (a/A = 5.5%)b. 26,129 (b/B = 1.02%)

2.37/ (b/a)c. 134,051 5.13/(c/b)

d. () 2.71e. 13,255 (e/c = 13.41)

Fluoroquinolone 2,817 31.92Nitrofurantoin 1,537 17.42Cephalosporin 4,138 46.89

Trimethoprim - Sulfamethoxazole 333 3.77

8,825 100.00

under use appropriate over use Total

Fluoroquinolone 367(13.03) 1,828(64.89) 622(22.08) 2,817(100)

Nitrofurantoin 1,343(87.38) 128(8.33) 66(4.29) 1,537(100)

Cephalosporin 739(17.86) 3,209(77.55) 190(4.59) 4,138(100)

Trimethoprim - Sulfamethoxazole 13(3.90) 135(40.54) 185(55.56) 333(100)

4,264(27.90) 5,300(60.06) 1,063(12.05) 8,825(100)

Fluoroquinolone 39 16.88Cephalosporin 138 59.74

Amoxicillin - Clavulanic acid 38 16.45

Trimethoprim - Sulfamethoxazole

16 6.93

231 100.00

under use appropriate over use Total

Fluoroquinolone 21(53.85) 16(41.02) 2(5.13) 39(100)

Amoxicillin - Clavulanic acid 7(18.42) 19(50.00) 12(31.58) 38(100)

Cephalosporin 81(58.7) 55(39.85) 2(1.45) 138(100)

Trimethoprim - Sulfamethoxazole 4(25.00) 2(12.50) 10(62.50) 16(100)

113(48.92) 92(39.83) 26(11.26) 231(100)

()

Odds ratio95

-0.8606 0.1238

(12~20)

21-40 -0.0279 0.1110 0.972 0.782~1.209

41-60 0.2641 0.1108 1.302* 1.048~1.618

>60 0.4064 0.1154 1.501** 1.197~1.882

()

-0.1231 0.0727 0.884 0.767~1.020

-0.2781 0.0652 0.757 *** 0.666~0.860

-0.0317 0.0725 1.311 0.959~1.792

0.0472 0.0654 1.048 0.922~1.192

-0.5769 0.1570 0.562** 0.413~0.760

()

0.3721 0.1797 1.451* 1.020~2.064

0.4524 0.1861 1.572* 1.092~2.264

0.2788 0.1718 1.322 0.944~1.851

*P

()

Odds Ratio95

()

0.3017 0.1907 1.352 0.930~1.965

0.1584 0.1799 1.172 0.823~1.667

-0.1549 0.1798 0.857 0.602~1.219

()

-0.3209 0.0969 0.725** 0.600~0.877

0.2282 0.0918 1.256* 1.050~1.504

0.2706 0.1595 1.311 0.959~1.792

-0.5851 0.2594 0.557* 0.335~0.926

0.4765 0.0698 1.610*** 1.405~1.846

-0.1544 0.0933 0.857 0.714~1.029

-0.2116 0.1727 0.809 0.577~1.135

-0.4607 0.1836 0.631* 0.440~0.904

-0.4107 0.3314 0.663 0.346~1.270#-2Log Likelihood=11575.1522=299.4373, DF=23(P

()

*P

()

*P

60

()--FluoroquinoloneNitrofurantoinCephalosporin

Trimethoprim Sulfamethoxazole

60.06

27.912.05

cephalosporin46.89% 22.45%

Trimethoprim Sulfamethoxazole3.77% 59.46%

Nitrofurantoin17.42% 91.67%

87.38%

61

()--

62

()--FluoroquinoloneCephalosporin Amoxicilli Clavulanic acidTrimethoprim Sulfamethoxazole

48.92

39.8311.26

cephalosporin59.74%

60.15% 58.7%

Trimethoprim

Sulfamethoxazole

6.93% 87.5%

63

()--

(Evidence-based treatment of UTI)(infection)(urinary tract infectionUTI)Urine culture and bacteriuria()() ? ?(systematic review)National Guideline Clearinghouse National Guideline Clearinghouse(presumed UTI)(definite UTI)(Uncomplicated UTI) (Complicated UTI) (uncomplicated acute bacterial cystitis)(acute pyelonephritis) 25 26 (asymptomatic bacteriuria)(acute cystitis in women) (recurrent cystitis in women)()(acute pyelonephritis in women)()(acute pyelonephritis in women) (UTI in pregnancy)(acute cystitis in adult men) (acute prostatitis) (chronic bacterial prostatitis) (chronic abacterial prostatitis) (complicated UTI)(complicated UTI)(complicated UTI) () ()/ ()()()()()--()--()--()-- 64