General introduction

The Dutch Working Party on Antibiotic Policy (SWAB; Stichting Werkgroep Antibiotica Beleid), established by the Dutch Society for Infectious Diseases (VIZ), the Dutch Society of Medical Microbiologists (NVMM) and the Dutch Society for Hospital Pharmacists (NVZA), coordinates activities in the Netherlands aimed at optimalization of antibiotic use, containment of the development of antimicrobial resistance, and limitation of the costs of antibiotic use. By means of the evidence-based development of guidelines, SWAB offers local antibiotic and formulary committees a guideline for the development of their own, local antibiotic policy.

 

DEFINITION OF COMPLICATED UTI

Differentiation between uncomplicated and complicated urinary tract infections (UTIs) has implications for the therapy, because the risks of complications or treatment failure are increased for patients with a complicated UTI.

The Guideline committee decided to use the following definition: an uncomplicated UTI is cystitis in a woman who is not pregnant, is not immunocompromised, has no anatomical and functional abnormalities of the urogenital tract, and does not exhibit signs of tissue invasion and systemic infection (1), (2).

All other UTIs are considered to be complicated UTIs. Exceptions for men are described in the section: What is the optimal treatment of urinary tract infections in men?

For the definition of uncomplicated pyelonephritis we follow the definition used in the recent updated guideline of the Infectious Disease Society of America (IDSA) for the treatment of uncomplicated UTI (also uncomplicated pyelonephritis) (3):

“Acute uncomplicated pyelonephritis is defined as pyelonephritis limited to premenopausal, nonpregnant women with no known urological abnormalities or comorbidities. It should be noted that women who are postmenopausal or have well-controlled diabetes without urological sequelae may be considered by some experts to have uncomplicated UTI, but a discussion of specific management of these groups is outside the scope of the present guideline and the IDSA guideline” (3).

Complicated pyelonephritis is defined as pyelonephritis in all other patient groups.

 

All UTIs which are not uncomplicated are considered to be complicated UTIs.

In general, a differentiation can be made in two patient groups:

1. UTI with systemic symptoms as fever or delirium.
2. UTI in a host with an increased chance for a complicated course: i.e. all men, pregnant women, patients with anatomical or functional abnormalities of the urinary tract, with a urinary catheter, with renal diseases (polycystic kidney disease, renal stones, renal transplant patients), and/or with other concomitant immunocompromising diseases such as, for example, diabetes.

 

In some guidelines, older women with uncomplicated UTI are considered to have a complicated UTI and are therefore treated for a longer period than younger patients. However, in a Cochrane review, 15 studies (1644 elderly women) were identified comparing single dose, short-course (3-6 days) and long course (7-14 days) antibiotic treatment for uncomplicated symptomatic UTI in elderly women. The conclusion was that, on the basis of the evidence available at present, a duration of antibiotic treatment of 3-6 days could be sufficient for treating uncomplicated UTIs in elderly women (4), (5). Therefore, the Guideline committee decided that patients older than 65 years are not considered as patients with an increased chance of a complicated course, unless they belong to one of the other above-mentioned patient groups with an increased risk for the development of complications of a UTI. 

Recurrent UTIs are recurrences of uncomplicated and/or complicated UTIs, with a frequency of at least 3 UTIs/year or 2 UTIs in the last 6 months.

 

LEVEL OF EVIDENCE

Table 1. Methodological quality of individual studies

Evidence level	Definition
A1   A2	Systematic review of at least two independent A2 level studies   Randomised controlled trial (RCT) of sufficient methodological quality and power or Prospective cohort study with sufficient power and with adequate confounding corrections
B	Comparative study lacking the same quality as mentioned in A2 (including patient-control and cohort studies) or Prospective cohort study lacking the same quality as mentioned in A2, retrospective cohort study or patient-control study
C	Non-comparative study
D	Evidence based on the opinion of members of the Guideline committee

 

Table 2. Levels of evidence (CBO. Evidence-based Richtlijnontwikkeling, handleiding voor werkgroepleden. Utrecht: CBO; 2007)

Evidence level	Definition
Level 1	Study of level A1, or at least two independent studies of level A2
Level 2	One study of level A2, or at least two independent studies of level B
Level 3	One study of level B or C
Level 4	Expert opinion