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Urinary Tract Infections in Adults

Translated from the original French version published October 2009

This clinical guide is provided for information purposes and is not a substitute for the practitioner’s judgment.

GENERAL

DIAGNOSISUrine analysis test (microscopic or stick): simple, low cost and reliable• Presenceofnitrites,leukocytesandde novourinarytractsymptoms:goodpredictivevalueofUTI• Absenceofnitritesorleukocytes:goodnegativepredictivevalue

Urineculture• NotveryusefulinuncomplicatedUTIs(exceptifreccurence<1month)• RecommendedincomplicatedUTIsorifpersistentsymptoms

TREATMENT GUIDELINES• Asymptomaticbacteriuria:• Treatonlypregnantwomenandpatientsundergoinggenito-urinarysurgery.• Antimicrobialtherapyinpregnantwomenmustbeadaptedtotheircondition.

90%ofurinarytractinfections(UTIs)arecausedbyenterobacteria.• Mostcommonpathogens:Escherichia coli, Staphylococcus saprophyticus, enterococci

UncomplicatedUTIsoccur:• Usuallyinwomenofchildbearingage• Inlowerurinarytract,withoutanatomicabnormality

ComplicatedUTIsoccurin:• Menandchildren• Pregnantwomen• Patientswithurinarycathetersorthosewaitingforurinarycatheterization• Upperurinarytract• Incaseof:

- Anatomicabnormalityoftheurinarytract - Diabetesmellitus- Immunosuppression - Symptomsdevelopingforover7days

Uncomplicated UTIs

3-daytherapy:• Thestandardfortreatinguncomplicatedcystitisinwomen.Mayalsobeusedinwomenover65 withoutanatomicabnormalityoftheurinarytract.

• OnlyTMP-SMXandfluoroquinolonesmaybeprescribedfor3days.

Trimethoprim-sulfamethoxazole(TMP-SMX):• InQuébec,approximately15%ofenterobacteriaareresistanttoTMP-SMX.• TMP-SMXisfirst-linetreatmentEXCEPTwhenlocalresistanceexceeds20%, whentherehasbeenrecentantimicrobialtreatmentwithTMP-SMXorrecenthospitalization.

• Itispreferabletoknowtheprevalenceoflocalresistancebeforeprescribing.• Incaseofsulfonamideallergy,trimethoprimaloneisanalternative.

β-lactamsandnitrofurantoin:• Efficacyprovenin7-daycourses.

* Adjustdosageaccordingtorenalfunction.† Theantibioticsarelistedinalphabeticalorderoftheirgenericnamewithintheirgroup.Onlyonebrandnameproductislistedalthoughseveralmanufacturers maymarketotherbrandnames.

‡Cefadroxil(Duricef®),Cefprozil(Cefzil®),Cephalexin.

REFERENCESLuttersM,Vogt-FerrierNB.Antibioticdurationfortreatinguncomplicated,symptomaticlowerurinarytractinfectionsinelderlywomen.CochraneDatabaseSystRev.2008Jul16;(3):CD001535.WarrenJW,AbrutynE,HebelJR,etal.Guidelinesforantimicrobialtreatmentofuncomplicatedacutebacterialcystitisandacutepyelonephritisinwomen.ClinInfectDis.1999;29:745-58.Please note that other references have been consulted.

Urinary Tract Infections in AdultsThisguidewasdevelopedwiththecollaborationoftheprofessionalcorporations(CMQ,OPQ),thefederations(FMOQ,FMSQ)andQuébecassociationsofpharmacistsandphysicians.

Acute pyelonephritis (APN)

• Inpatientscapableoftakingoraltherapy:- Fluoroquinolonesconstitutefirst-lineempiricaltherapy.- Pregnancymustbeexcludedinwomenofchildbearingage.

• InsevereAPNcasesrequiringhospitalization:- OralorparenteralfluoroquinoloneOR- CombinationofaminoglycosideORextended-spectrumcephalosporinWITHampicillinifenterococcusissuspected.

• DurationoftherapyforAPNis14days;initiateoraltherapyassoonaspossible.• Thepresenceorpossibilityofurinarytractobstructionisconsideredanemergency.

Treatment of uncomplicated urinary tract infections*

Antibiotic† Oral dosage Duration

Fluoroquinolone

Ciprofloxacin(Cipro®) 250mgevery12hours

3 days

CiprofloxacinXL(CiproXL®) 500mgevery24hours

Levofloxacin(Levaquin®) 250mgevery24hours

Norfloxacin(Norflox®generic) 400mgevery12hours

Ofloxacin(Oflox®generic) 200mgevery12hours

Sulfonamide

TMP-SMX(SeptraDS®generic) 1tab.every12hours

TMP(Apo-Trimethoprim®) 100mgevery12hours

Other

Nitrofurantoin(Macrobid®) 100mgevery12hours

7 days

Nitrofurantoin(Novo-Furantoin®) 50-100mgevery6hours

β-lactams

Amoxicillin-clavulanatepotassium(Clavulin®) 250mgevery8hoursor 500mgevery12hours

Narrowspectrumcephalosporins‡ex.:Cefadroxil(Duricef®)

500mgevery12hours

Treatment of acute pyelonephritis and complicated urinary tract infections*

Antibiotic† Dosage Duration

Oral therapy14DAYSEXCEPT:Youngwomenwithoutanatomicalabnormalityoftheurinarytracttreatedwithfluoroquinolones,inwhichcase:7days

Ciprofloxacin(Cipro®) 500mgPOevery12hours

CiprofloxacinXL(CiproXL®) 1000mgPOevery24hours

Levofloxacin(Levaquin®) 500mgPOevery24hours

Parenteral therapy (severe cases)

Initiateoraltherapyassoonaspossible

Ciprofloxacin(Cipro®) 400mgIVBID

Levofloxacin(Levaquin®) 500mgIVDIE

Aminoglycoside+ampicillinORExtended-spectrumcephalosporin+ampicillin