What are the appropriate treatment durations for patients with CA-UTI?
See general treatment guidelines for the treatment duration of CA-UTI with systemic symptoms.
A 5-day antimicrobial regimen may be considered for women who develop a CA-UTI without upper tract and systemic symptoms.
It is desirable to limit the duration of treatment, especially for milder infections and infections that respond promptly to treatment, to reduce the selection pressure for drug-resistant flora, especially in patients on long-term catheterization. The sample size for the above-mentioned study (20) was for all patients with a complicated UTI and not for the subgroup of patients with a CA-UTI. Only the microbiologic eradication rate was mentioned in this subgroup, which was higher in the levofloxacin than in the ciprofloxacin group. However, the Guideline committee has the opinion that the clinical resolution of symptoms is a more important endpoint.
Concerning the treatment duration, the Guideline committee considers CA-UTI with systemic symptoms to be a complicated UTI and refers to the recommendations as described in the module on treatment duration. Shorter durations of treatment are preferred in appropriate patients to limit development of resistance. Therefore, the Guideline committee is of the opinion that a shorter course, such as a 5-day regimen commonly used in women with uncomplicated lower UTI, is also reasonable in women with mild CA-UTI without upper tract and systemic symptoms.
Regimens should be adjusted as appropriate depending on the culture and susceptibility results and the clinical course.
This guideline does not include individual introductions to each module. A general introduction can be found in the attachments under the heading 'related'.
In 6 of 9 (67%) women with upper tract CA-UTI 10 days of TMP-SMX treatment led to resolution [(98) C].
Women with lower tract CA-UTI within 14 days after catheter removal had similar resolution rates with single-dose therapy or 10 days of therapy with TMP-SMX, with better outcomes in women aged less than 65 years [(98) B].
Men and women with neurogenic bladders managed by intermittent catheterization have similar rates of cure, persistence, and relapse after a 10-day or 3-day course of an antimicrobial to which the infecting strain was susceptible [(99) B].
In patients with spinal cord injury, treatment of mild CA-UTI for 14 days leads to improved clinical and microbiological outcomes, compared with short-course (3 days) therapy [(100) A2].
In patients with acute pyelonephritis or complicated UTI and a catheter the microbiologic eradication rate was higher in the levofloxacin group 750 mg intravenously or orally once daily (79%) than ciprofloxacin 500 mg orally twice daily for 10 days (53%) (95% CI, 3.6% to 47.7%). Clinical outcomes in catheterized subjects were not reported [(20) A2].
There is a wide spectrum of conditions represented in patients with complicated UTI, including those with CA-UTI, such as an uncomplicated cystitis, pyelonephritis, pyelonephritis with abscess, prostatitis, and bacteremia. There are no published trial data that provide treatment outcomes for these different types of patients with CA-UTI and, thus, the optimal duration of antimicrobial treatment for CA-UTI is not yet known. In published reviews the recommended treatment durations for complicated UTI range from 7-21 days (80), depending on the severity of the infection.
In an RCT, Harding et al. demonstrated that women with lower tract CA-UTI within 14 days after catheter removal had similar resolution rates with single-dose therapy or 10 days of therapy with TMP-SMX with better outcomes in women aged ≤ 65 years (98). For patients with lower tract symptoms alone, resolution rates with single-dose therapy or 10 days of therapy were similar: 11 of 14 (79%) and 13 of 16 women (81%), respectively. Infection was resolved more often in women aged ≤ 65 years than in older women: 62 of 70 (89%) vs. 24 of 39 women (62%) (P<0.001). Bacteriuria resolved spontaneously more frequently in younger women: 14 of 19 (74%) compared with 1 of 23 older women (4%) (P< 0.001). Single-dose therapy resolved infection in 31 of 33 patients (94%) who were aged ≤ 65 years (98). In women with upper tract CA-UTI, 10 days of treatment with TMP-SMX led to resolution in 6 of 9 women (67%) (98).
In a study of 46 men and women with neurogenic bladders managed by intermittent catheterization, a 10-day course of an antimicrobial to which the infecting strain was susceptible (most received TMP-SMX) was no more effective than a 3-day course in treating episodes (29 in each group) of CA-bacteriuria, about half of which were CA-UTI (41% in the 3-day group vs. 55% in the 10-day group) (99). Rates of cure, persistence, and relapse were similar in the two treatment groups.
Another randomized, double-blind, placebo-controlled trial was performed comparing 3-day and 14-day regimens of ciprofloxacin, 250 mg twice daily, for the treatment of mild CA-UTI in 60 patients with spinal cord injury, most using intermittent catheterization. Patients with pyelonephritis or symptoms of systemic infection were excluded (100). Microbiological cure, but not clinical cure, at long-term follow-up was significantly better among patients who received therapy for 14 days than among patients who received therapy for 3 days. Microbiological and symptomatic relapse were significantly more common in the 3-day treatment group. The authors concluded that for patients with spinal cord injury, treatment of CA-UTI for 14 days leads to improved clinical and microbiological outcomes, compared with short-course therapy. Since there was no difference in clinical outcomes between the two treatment groups at long-term follow-up, it seems likely that the optimal treatment duration in such patients lies somewhere between 3 and 14 days.
In another multicenter, double-blind, randomized, non-inferiority study of 619 patients with acute pyelonephritis or complicated UTI, levofloxacin 750 mg intravenously or orally once daily for 5 days was compared with ciprofloxacin 400 mg intravenously and/or ciprofloxacin 500 mg orally twice daily for 10 days (20). A detailed description of the types of complicated UTI in the treatment groups was not provided, but 68 (11%) patients were catheterized. Clinical success rates post-treatment were similar (81% vs. 80%, respectively), as were microbiologic eradication rates (80% vs. 80%, respectively). Microbiologic eradication was lower in subjects with a catheter vs. those without a catheter, but among catheterized patients the microbiologic eradication rate was higher in the levofloxacin group (79%) than in the ciprofloxacin group (53%) (95% CI 3.6-47.7%). Clinical outcomes in catheterized subjects were not reported.
Search and select
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.
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.
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.
This guideline does not include patient involvement.
Method of development
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.
Searches are available upon request. Please contact the Richtlijnendatabase.