Antimicrobial therapy of complicated urinary

Initiative: SWAB Number of modules: 14

Systemic antimicrobial prophylaxis

Question

Is systemic antimicrobial prophylaxis necessary in patients with a urinary catheter?

Recommendation

It is not recommended to prescribe antibiotic prophylaxis in patients with short-term or long-term urinary catheters, or in those who catheterize themselves intermittently over prolonged periods and, as a result, there is no need to screen for bacteriuria in these patients.

Considerations

Antibiotic prophylaxis sometimes seems effective but, on the other hand, will result in the development of resistance of the commensal flora (84). Differences in the incidence of symptomatic UTIs between groups of patients who did and did not receive antibiotic prophylaxis were small. Therefore, the Guideline committee does not recommend antibiotic prophylaxis. As a result there is no need to screen for bacteriuria in patients with a short or long-term urinary catheter.

Evidence

This guideline does not include individual introductions to each module. A general introduction can be found in the attachments under the heading 'related'.

Level 1  

Antibiotic prophylaxis decreases fivefold the incidence of bacteriuria in patients with a short-term indwelling catheter [(81) A1].

 

Level 1  

No eligible studies are present to answer the questions what the best catheterization method is: indwelling urethral, suprapubic or intermittent, in terms of effectiveness, complications, quality of life and cost-effectiveness [(82) A1; (80) D].

Level 1  

Antibiotic prophylaxis decreases fivefold the incidence of bacteriuria in patients who catheterize themselves intermittently over prolonged periods [(82) A1].

Level 1 

Antibiotic prophylaxis decreases the incidence of symptomatic UTI in patients with a short-term indwelling catheter (RR 0.20 (95% CI 0.06-0.66)  [(81) A1].   

Level 3 

Antibiotic prophylaxis decreases the incidence of symptomatic UTI in patients with a long-term indwelling catheter  [(83) B].

Results of studies included in a Cochrane review about short-term urinary catheter use provide evidence that antibiotic prophylaxis, compared to giving antibiotics when clinically indicated, reduced the rate of symptomatic UTI [RR 0.20 (95% CI 0.06-0.66)] in female patients with abdominal surgery and a urethral catheter for 24 hours. Receiving antibiotics the first 3 postoperative days, or from postoperative day 2 until catheter removal, reduced the rate of bacteriuria (fivefold) and other signs of infection such as pyuria and gram-negative isolates in patients' urine in surgical patients with bladder drainage for at least 24 hours postoperatively. There is also some evidence that prophylactic antibiotics reduced bacteriuria in non-surgical patients (81).

 

Results of studies included in a Cochrane review about long-term urinary catheter use show that no eligible studies are present to address the following questions in terms of effectiveness, complications, quality of life and cost-effectiveness: Is indwelling urethral catheterization better than suprapubic catheterization? Is indwelling urethral catheterization better than intermittent catheterization? Is suprapubic catheterization better than intermittent catheterization? Is giving antibiotics when microbiologically indicated better than giving antibiotics when clinically indicated?

 

For patients using intermittent catheterization, the limited evidence available suggests that antibiotic prophylaxis reduces the number of episodes of bacteriuria (asymptomatic and symptomatic). For patients using urethral catheterization no data were available (82).

 

To answer the question whether antibiotic prophylaxis is better than giving antibiotics when clinically indicated (having a symptomatic UTI), the evidence available is not sufficient as a basis for determining practice. For patients using intermittent catheterization the data were inconclusive. For patients using indwelling urethral catheterization, only a single crossover trial with 34 elderly inpatients investigated this issue and results show fewer episodes of symptomatic UTI in the prophylaxis (norfloxacin) group (1 in 276 catheterization weeks vs. 12 in 259 weeks) (83).

Databases were Pubmed and the Cochrane Library.

Keywords: urinary tract infection AND catheter or bacteriuria AND catheter

Limits: Last 3 years for Pubmed (guideline Catheter-associated UTI was published in 2009), English, adults, humans, clinical trials, guideline, meta-analysis, RCT

Pubmed: 36 results, all titles screened, 3 abstracts screened, 3 additional articles included

Cochrane Library: 12 results, all titles screened, 2 abstracts screened, 2 reviews included

 

Articles about special catheters as prevention methods or after certain procedures (for example, after operations/interventions) were excluded.

Some parts are used from the original text of the Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America (80).

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This guideline does not include evidence tables.

Authorization date and validity

Last review  : 01-03-2013

Last authorization  : 01-03-2013

Planned reassessment  :

This guideline was developed and approved by representatives of the professional medical societies, mentioned in the introduction and methods sections and therefore represents the current professional standard in 2013. The guideline contains general recommendations. It is possible that, in individual cases, these recommendations do not apply. Applicability of the guideline in clinical practice resorts to the responsibility of every individual practitioner. Facts or circumstances may occur, in which deviation of the guideline is justified, in order to provide optimal quality of care for the patient.

Initiative and authorization

Initiative:
  • Stichting Werkgroep Antibioticabeleid
Authorized by:
  • Nederlands Huisartsen Genootschap
  • Nederlandse Internisten Vereniging
  • Nederlandse Vereniging voor Medische Microbiologie
  • Nederlandse Vereniging voor Obstetrie en Gynaecologie
  • Nederlandse Vereniging voor Urologie

General details

Development of this guideline was supported and financed by the SKMS (Kwaliteitsgelden Medisch Specialisten).

Scope and target group

The objective of these guidelines is to update clinicians with regard to important advances and controversies in the antibiotic treatment of patients with complicated urinary tract infections (UTIs).

 

The guidelines described here cover the empirical antimicrobial therapy of adult patients (for this guideline 12 years or older) with a complicated UTI admitted to a hospital (emergency room or ward) in the Netherlands. Uncomplicated UTIs are treated predominantly by the general practitioner. For the relevant guidelines, see the recently updated Standard for Urinary Tract Infections of the Dutch Society of General Practitioners (NHG). We have tried to adhere to this standard insofar as possible. Urethritis and epididymitis are not included in this guideline.

The Guidelines give a general therapy advice for all UTI with systemic symptoms because, at first presentation of a patient, it is not always possible to differentiate between an acute prostatitis, pyelonephritis or urosepsis. In addition, this differentiation has no consequences for the choice of empirical antimicrobial therapy. Apart from these general guidelines, we give specific advice for certain groups of patients separately.

Samenstelling werkgroep

Preparation of the guideline text was carried out by a multidisciplinary committee consisting of experts, delegated from the professional societies for infectious diseases (VIZ), medical microbiology (NVMM), hospital pharmacists (NVZA), urology (NVU), gynaecology (NVO), nephrology (NFN) and general practice (NHG). After consultation with the members of these professional societies, the definitive guideline was drawn up by the delegates and approved by the board of SWAB.

 

  • Dr. S.E. Geerlings (coordinator, SWAB), Internal Medicine/Infectious Diseases specialist, Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, Amsterdam
  • Dr. C. van Nieuwkoop (VIZ, NIV), Internal Medicine, Emergency Medicine and Infectious Diseases specialist, Department of Internal Medicine, Hagaziekenhuis, the Hague
  • E. van Haarst (NVU), Urologist, Department of Urology, St. Lucas Andreas Hospital, Amsterdam
  • Dr. M. van Buren (NFN), Internal Medicine and Nephrology specialist, Department of Internal Medicine, Hagaziekenhuis, the Hague
  • Dr. B.J. Knottnerus (NHG), General Practitioner, Department General Practice, Academic Medical Center, Amsterdam
  • Dr. E. E. Stobberingh (NVMM), Medical microbiologist, Lab Medical Microbiology, Maastricht Univerisity Medical Center, Maastricht
  • Prof. dr. C.J. de Groot (NVOG), Gynaecologist, Department of Obstetrics and Gynaecology, Vrije Universiteit Medical Center, Amsterdam
  • Prof. dr. J.M. Prins (SWAB), Internal Medicine/Infectious Diseases specialist, Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, Amsterdam

 

The Guideline committee would also like to thank Frederique Bemelman (nephrologist) for her comments on the chapter about renal transplantation and Albert Vollaard (infectious disease specialist) for his comments on the subchapter about methenamine.

Declaration of interest

The SWAB employs strict guidelines with regard to potential conflicts of interests as described in the SWAB Format for Guideline Development (www.swab.nl). Members of the preparatory committee reported the following potential conflicts of interest:

 

SE Geerlings: for the RCTs mentioned in the reference numbers 84 en 168 (Beerepoot et al.): Ref 84: Cranberry capsules and placebo capsules for this trial were delivered by Springfield Nutraceuticals, Oud Beijerland, The Netherlands. Ref 168: Chr Hansen A/S, Denmark has the patents for Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 and donated the placebo capsules for this trial.

E v Haarst: has received speaker fees on a national urological symposium from GlaxoSmithKline, the manufacturer of amoxicillin-clavulanic acid.

Other authors: no potential conflicts of interest declared.

Patient involvement

This guideline does not include patient involvement.

Method of development

evidence based

Implementation

This guideline does not include an implementation strategy.

Methods and proces

This guideline was drawn up according to the recommendations for evidence-based development of guidelines (6), (Evidence-Based Richtlijn-Ontwikkeling (EBRO) and Appraisal of Guidelines Research and Evaluation (AGREE), www.agreecollaboration.org). The guidelines are derived from a review of literature based on the 9 key questions concerning the treatment of UTI. Studies were assigned a degree of evidential value according to the handbook of the Dutch Institute for Healthcare Improvement (Centraal Begeleidingsorgaan/Kwaliteitsinstituut voor de gezondheidszorg, CBO) (CBO. Evidence-based Richtlijnontwikkeling, handleiding voor werkgroepleden. Utrecht: CBO; 2007). Conclusions were drawn, completed with the specific level of evidence, according to the grading system adopted by SWAB (Table 1 and 2). The only exception concerns Nethmap, an annual report from which the resistance surveillance data were used. The Guideline committee cannot give Nethmap a level of evidence and decided to use an asterix (*), but is of the opinion that the results can be given substantial weight, since the surveillance data described in Nethmap cover 30% of the Dutch population. Subsequently, specific recommendations were formulated.

In order to develop recommendations for the optimal treatment of UTI, the literature was searched for the key questions. For each question a literature search was performed in the PubMed database (January 1966 to January 2012) as well as in the Cochrane Register of Controlled Trials (CENTRAL). For resistance surveillance data NethMap 2011 was used, and for the interpretation of susceptibility test results, in addition, reports of the European Committee on Antimicrobial Susceptibility Testing (EUCAST) were used. When scientific verification could not be found, the guideline text was formulated on the basis of the opinions and experiences of the members of the Guideline committee.

Search strategy

Searches are available upon request. Please contact the Richtlijnendatabase.

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UTI in patients with Diabetes Mellitus