Philippine Clinical Practice Guidelines on UTI in Adults 2013 Update Part 1 PDF

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update...

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update (Part 1) O BI O L O G Y CR AN MI D R FO IN FE S O C IE T Y C TI O U S D IS INE PP EA LI S I ES PH ---1 -- 9 70 AD- This guideline is intended for use by a broad range of health care professionals, including general practitioners, medical specialists, administrators, policy makers and nurses. Suggested Citation Task Force on UTI 2013, Philippine Practice Guidelines Group in Infectious Diseases. Urinary Tract Infections in Adults 2013 Update. PPGG-ID Philippine Society for Microbiology and Infectious Diseases Volume ___ No ___ Quezon City, Philippines. Copyright PSMID 2013 ISBN ______ Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update Part 1 Uncomplicated Urinary Tract Infections Urinary Tract Infections in Pregnancy blank  Task Force Members Organizations: PSMID, POGS, PSN, PUA, PAFP Chair: Mediadora C. Saniel Co-chair: Marissa M. Alejandria Uncomplicated Urinary Tract Infection Cluster Thea C. Patino (Head) Evalyn A. Roxas (Head) Karen Marie R. Gregorio Annabelle M. Laranjo Kathryn U. Roa Rommel P. Sumilong Anna Marie S. Velasco Rosally P. Zamora Urinary Tract Infection in Pregnancy and Asymptomatic Bacteriuria in Adults Cluster Ricardo M. Manalastas Jr. (Head) Louella P. Aquino Shahreza L. Baquiran Sybil Lizzane R. Bravo Jennifer T. Co Maria Meden P. Cortero Lorina Q. Esteban Analyn F. Fallarme May Gabaldon Jill R. Itable Alfredo M. Lopez, Jr Helen V. Madamba Josefa Dawn V. Martin Erwin R. De Mesa Sharon Faith B. Pagunsan Oliver S. Sanchez Katha W. Ngo-Sanchez Research Associates: Richelle G. Duque Grace Kathleen T. Serrano Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 i  Table of Contents Introduction....................................................................................... 1 Methodology..................................................................................... 1 Acute Uncomplicated Urinary Tract Infections.................................. 5 Acute Uncomplicated Cystitis In Women.......................................... 7 Acute Uncomplicated Pyelonephritis In Women............................... 24 Urinary Tract Infections In Pregnancy.............................................. 43 Asymptomatic Bacteriuria In Pregnancy........................................... 45 Acute Cystitis In Pregnancy.............................................................. 57 Acute Uncomplicated Pyelonephritis In Pregnancy.......................... 65 Acknowledgement............................................................................ 74 List of Tables Table 1. Strength of Recommendation and Quality of Evidence......... 2 Table 2. Conditions that define complicated UTI............................ 9 Table 3. Accuracy of clinical signs and symptoms in the prediction of UTI..................................................... 11 Table 4. Antibiotics that can be used for AUC................................ 13 Table 5. Percent Resistance of Urinary E.coli (outpatient urine specimens).............................................................. 14 Table 6. Empiric treatment regimens for acute uncomplicated pyelonephritis........................................... 31 Table 7. Computed Likelihood Ratios for the different screening tests compared with urine culture.................... 50 Table 8. Antibiotics that can be used for asymptomatic bacteriuria in pregnancy................................................... 54 Table 9. Antibiotics that can be used for acute cystitis in pregnancy..................................................................... 61 Table 10. Empiric treatment regimens for acute uncomplicated pyelonephritis in pregnant women.................................... 71 List of Algorithms Algorithm 1. Evaluating a Woman with Symptoms of Acute Urinary Tract Infection............................................ 4 Algorithm 2. Management of Acute Uncomplicated Cystitis....... 21 Algorithm 3. Treatment of acute uncomplicated pyelonephritis in non-pregnant women.................. 39 Algorithm 4. Alternative diagnostic evaluation for asymptomatic bacteriuria in settings where urine culture is not available.................................. 55 ii Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 INTRODUCTION Urinary tract infections (UTI) were among the leading indications for seeking healthcare and using antimicrobials in the community and hospital settings. The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults were fi st p lished in and e ised in to p o ide p ima ca e ph sicians and specialists ith e idence ased ecommendations on the care of patients with UTI. The current guidelines further pdated the ecommendations ollo in an e tensi e e ie o mo e ecent lite at e This as the fi st time that the adin o ecommendations ssessment e elopment and al ation s stem as sed to de elop idelines in in ectio s diseases in the country. The outputs were consensus recommendations of a panel o clinicians con ened the hilippine ociet o ic o iolo and In ectio s iseases I in colla o ation ith the hilippine stet ic and necolo ical ociet hilippine ociet o eph olo hilippine cadem o amil h sicians and Philippine Urological Association (PUA). The oc s o the idelines as on dia nosis t eatment and p e ention o UTI in ad lts and consists o t o pa ts Part One – Acute Uncomplicated UTI and UTI in Pregnancy atT o s mptomatic acte i ia ec ent UTI and Complicated UTI In formulating optimal approaches to the care of both outpatients and inpatients ith UTI the panel conside ed se e al iss es elated to chan in p e alence and esistance patte ns o opatho ens a aila ilit and p actica ilit o dia nostic tests and cost e ecti eness and ecolo ical ad e se e ects collate al dama e o t eatment The idelines e e not intended to s pe sede a healthca e p o ide s so nd clinical d ment a iations in clinical p esentation p esence o como idities o a aila ilit o eso ces ma e i e adaptation of the recommendations. METHODOLOGY The I in colla o ation ith and U con ened a tas o ce o clinicians ep esentin di e ent e pe tise incl din in ectio s diseases neph olo amil medicine o stet ics and necolo olo and inte nal medicine The mem e s o this tas o ce e e di ided into o cl ste s each headed a senio specialist and se ed as the technical o in o p o o m latin the idelines The a eas co e ed e e Cl ste ncomplicated UTI ac te c stitis and p eloneph itis Cl ste UTI in p e nanc and as mptomatic acte i ia Cl ste C complicated UTI and Cluster D – recurrent UTI. Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  ach cl ste cond cted a e ie and anal sis o the ele ant n lish lite at e p lished since and o some topics e en ea lie st dies The alit o the e idence as e al ated sin the s stem as indicated in Ta le The cl ste then d a ted ideline ecommendations and aded them as T o dependin on the alit o the e idence alance o potential enefits and ha m and t anslation into p actice in specific settin s and patient o ps Th s hi h alit e idence did not necessa il constit te st on ecommendations con e sel st on ecommendations co ld a ise om lo alit e idence i the enefits o t ei h the ndesi a le conse ences. Table 1. Strength of Recommendation and Quality of Evidence1,2 Category Definition Strength of Recommendation Strong Desirable effects (benefits) clearly outweigh the undesirable effects (risks) Conditional Desirable effects probably outweigh the undesirable effects but the recommendation is applicable only to a specific group, population, or setting; or the benefits may not warrant the cost or resource requirements in all settings Weak Desirable and undesirable effects closely balanced; or uncertain, new evidence may change the balance of risk to benefit No recommendation Further research is required before any recommendation can be made Quality of Evidence High Consistent evidence from well-performed RCTs or strong evidence from unbiased observational studies; further research is very unlikely to change confidence in the estimate of the effect Moderate Evidence from RCTs with important limitations or moderately strong evidence from unbiased observational studies; further research is likely to have an important impact on confidence in the estimate of the effect Low Evidence for ≥ one critical outcome from observational studies, from RCTs with serious flaws or from indirect evidence; further research is very likely to have an important impact in the estimate of effect and is likely to change the estimate Very Low Evidence for ≥ one critical outcome from unsystematic clinical observations or very indirect evidence; any evidence of effect is very uncertain Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  In addition to alit o e idence the ollo in domains e e conside ed in adin the st en th o the ecommendations a alance o enefits e s s ha ms and dens al es and p e e ences Is the ecommendation li el to e idel accepted o is the e si nificant a ia ilit o nce taint in al es and p e e ences that the ecommendation is nli el to be accepted? c eso ce implications financial costs implications in ast ct e e ipment h man eso ces e pe tise cost e ecti eness d easi ilit Is the ecommendation achie a le in the settin where the greatest impact is expected? se ies o ace to ace meetin s o the tas o ce ith ep esentati es om all o cl ste s as held to disc ss each cl ste s d a t o tp ts The tas o ce mem e s de eloped a consens s in adin the alit o the e idence and st en th o the ecommendations sin the techni e Th o ho t the de elopment p ocess e pe t ad ice on methodolo ical iss es as p o ided a tas o ce mem e p oficient in the s stem ta les s mma i in the alit o the e idence et ie ed e e ene ated o each ideline estion e ments o the idelines e e p esented in a io s o a incl din ann al con entions o specialt societies s ch as and I to elicit eed ac The idelines e e finali ed a te a e mo e meetin s and e mail co espondence amon the tas o ce mem e s and cl ste heads t e la inte als the tas o ce leade s ill dete mine the need o e isions to the idelines Implementation st ate ies ill also e pe iodicall e ie ed References att man ist n alc tte lonso Coello et al an eme in consens s on atin alit o e idence and st en th o ecommendations att man n alc tte ist i e ati et al oin om e idence to ecommendations Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 Algorithm 1. Evaluating a Woman with Symptoms of Acute Urinary Tract Infection Woman with ≥1 *dysuria, frequency, urgency, hematuria, symptoms of UTI* discomfort in lower abdomen es See Section on UTI in pregnancy Pregnant? No Recurrent es ≥2x/year? See Section on Recurrent UTI No es Do urinalysis, urine culture to establish diagnosis With risk factors for Consider initiating empirical treatment complicated UTI? See Section Complicated UTI No Consider Acute Uncomplicated Pyelonephritis With flank pain or es Do urinalysis, urine culture to establish diagnosis fever? Consider empiric treatment See Section on Acute Uncomplicated Pyelonephritis No Low to intermediate probability of UTI (~20%) With vaginal es Consider Sexually Transmitted Infections discharge? Do pelvic examination (including cervical culture when appropriate), urinalysis, urine culture, urine Chlamydia to establish diagnosis No See Section on Acute Uncomplicated Cystitis With clear history of ≥1 symptoms of UTI – es High probability of AUC (~90%) acute onset of dysuria, Start empiric treatment without urinalysis, urine culture frequency, urgency, See Section on Acute Uncomplicated Cystitis hematuria? No Perform dipstick urinalysis High probability of AUC (~80%) Dipstick result es Start empiric treatment without urine culture positive? See Section on Acute Uncomplicated Cystitis No Low to intermediate probability of UTI (~20%) Consider urine culture or close clinical follow-up and pelvic examination including cervical cultures and radiologic imaging when appropriate See Section Uncomplicated Urinary Tract Infection Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 Acute uncomplicAted urinAry trAct infections Acute Uncomplicated Cystitis Acute Uncomplicated Pyelonephritis Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  ACUTE UNCOMPLICATED URINARY TRACT INFECTIONS ACUTE UNCOMPLICATED CYSTITIS IN WOMEN Section Summary efinition o ac te ncomplicated c stitis UC Clinicall UC is s spected in p emenopa sal non p e nant omen p esentin ith ac te onset o d s ia e enc enc and oss hemat ia and itho t a inal discha e U inal sis is not necessa to confi m the dia nosis o UC in omen p esentin ith one o mo e o the a o e s mptoms o UTI in the a sence o a inal discha e and complicatin conditions en me ated in Ta le omen p esentin ith ina s mptoms pl s a inal discha e sho ld nde o the e al ation Conditions that define complicated UTI cUTI m st e a sent as o tained on histo ta in Strong recommendation, High quality of evidence Approach to management mpi ic anti iotic t eatment is the most cost e ecti e app oach in the management of AUC. e t eatment ine c lt e and sensiti it is T ecommended tanda d ine mic oscop and dipstic le oc te este ase and nit ite tests a e not p e e isites o t eatment Strong recommendation, High quality of evidence Antibiotic treatment Antibiotics recommended for use in AUC are presented in Table ficac in te ms o clinical c e cost e ecti eness sa et and tolerability were considered in the choice of antibiotics. In addition the p opensit to ca se collate al dama e and local s scepti ilit ates e e i en eate ei hts in the choice o antibiotic recommendations. Ampicillin or amoxicillin should NOT be used for empirical t eatment i en the elati el poo e ficac and e hi h p e alence o antimic o ial esistance to these a ents o ld ide Strong recommendation, High quality of evidence T imethop im s l ametho a ole m I o th ee da s sho ld e sed o c lt e p o en s scepti le opatho ens d e to hi h p e alence o local esistance and high failure rates. Strong recommendation, High quality of evidence it o antoin monoh d ate mac oc stals m I o fi e da s is ecommended as the fi st line t eatment o UC d e to its hi h e ficac minimal esistance minimal ad e se e ects lo Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 7  p opensit o collate al dama e and easona le cost o e e the nit o antoin monoh d ate mac oc stal o m lation is not locall a aila le Th s nit o antoin mac oc stal o m lation m is ecommended t it sho ld e i en o times a da o fi e da s Strong recommendation, High quality of evidence os om cin in a sin le dose is also a ecommended anti iotic d e to its hi h e ficac con enience o a sin le dose lo p opensit o collate al dama e ood acti it a ainst m ltid esistant opatho ens and minimal ad e se e ects o e e the e a e no local esistance data to date Strong recommendation, High quality of evidence i mecillinam m I o th ee to se en da s can e sed in a eas he e it is a aila le as it has easona le t eatment e ficac o e e it is not c entl a aila le in the co nt ocal esistance data is also a sent Strong recommendation, High quality of evidence inolones sho ld T e sed as a fi st line d despite thei e ficac d e to the hi h p opensit o collate al dama e Strong recommendation, High quality of evidence eta lactam a ents incl din amo icillin cla lanate ce aclo ce dini ce podo ime p o etil ce ti ten and ce o ime a e appropriate choices for therapy when other recommended agents cannot be used. Strong recommendation, High quality of evidence Duration of treatment it o antoin sho ld e i en o fi e da s hile os om cin is i en as a sin le dose o the alte nati e a ents th ee da co se o o o inolone is ecommended se en da e imen o eta lactams amo icillin cla lanate ce aclo ce dini cefi ime ce podo ime p o etil ce ti ten and ce o ime is ecommended Duration of treatment for elderly women In othe ise health elde l omen ith UC the ecommended duration of treatment is the same as with the general population ee Ta le Strong recommendation, High quality of evidence Course of action for patients who do not respond to treatment atients hose s mptoms o sen o do not imp o e a te completion o t eatment sho ld ha e a ine c lt e done Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  and antibiotic should be empirically changed pending result of sensiti it testin atients hose s mptoms ail to esol e a te t eatment sho ld be managed as complicated UTI. Strong recommendation, Low quality of evidence ost t eatment la o ato tests o tine post t eatment ine c lt e and inal sis in patients hose s mptoms ha e completel esol ed a e T ecommended as it does not p o ide an added clinical enefit Strong recommendation, Low quality of evidence Recommendations and Summary of Evidence 1. When is AUC suspected in women? Clinically, AUC is suspected in premenopausal non- pregnant women presenting with acute onset of dysuria, frequency, urgency, and gross hematuria; and without vaginal discharge. Urinalysis is not necessary to confirm the diagnosis of AUC in women presenting with one or more of the above symptoms of UTI in the absence of vaginal discharge and Women presenting with urinary symptoms plus vaginal discharge should undergo further evaluation. Conditions that define complicated UTI must be absent as obtained on history-taking. Strong recommendation, High quality of evidence Table 2. Conditions that define complicated UTI1–7 Presence of an indwelling urinary catheter or intermittent catheterization Incomplete emptying of the bladder with >100 ml retained urine post-voiding Impaired voiding due to neurogenic bladder, cystocoele Obstructive uropathy due to bladder outlet obstruction, calculus, urethral or ureteric strictures, tumors Vesicoureteral reflux & other urologic abnormalities including surgically created abnormalities Chemical or radiation injuries of the uroepithelium Peri- or post-operative UTI Azotemia due to intrinsic renal disease Renal transplantation Diabetes mellitus Immunosuppressive conditions – e.g. febrile neutropenia, HIV-AIDS UTI caused by unusual pathogens (M. tuberculosis, Candida spp.) UTI caused by antibiotic-resistant or multi-drug resistant organisms (MDROs) UTI in males except in young males presenting exclusively with lower UTI symptoms Urosepsis Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 Summary of Evidence In a ecent s stematic e ie o st dies patients iesen et al the dia nostic acc ac o s mptoms and si ns o ncomplicated UTI as compa ed to the old standa d ine c lt e ac oss th ee di e ent e e ence standa ds and C U m i s mptoms e e si nificant in dete minin the p o a ilit o UTI The p esence o d s ia e enc enc hemat ia and noct ia inc eased the p o a ilit o UTI ith hemat ia ha in the hi hest dia nostic tilit ositi e li elihood atio sensiti it confidence inte al CI specificit CI The p esence o a inal discha e on the othe hand decreases the probability of UTI. n ea lie s stematic e ie ent et al also assessed the usefulness of signs and symptoms in the diagnosis of UTI. In this e ie the p esence o d s ia e enc hemat ia ac pain and costo e te al tende ness inc eased the p o a ilit o UTI hile the a sence o d s ia a sence o ac pain positi e histo o a inal discha e positi e histo o a inal i itation and the findin o a inal discha e on ph sical e amination dec eased the p o a ilit of UTI. The findin s o iesen et al e e simila to the findin s o ent et al he e no one s mptom o si n as s ficient to ma e the diagnosis of UTI with certainty. A combination of signs and symptoms was needed to determine the diagnosis. The two studies differed in that Bent et al. combined the different studies with different diagnostic th esholds an in et een C U m and C Um hile iesen et al anal ed the st dies ased on th ee defined dia nostic th esholds C Um C U m and C Um Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 Table 3. Accuracy of clinical signs and symptoms in the prediction of urinary tract infections* Signs/Symptoms Summary Positive Summary Negative Summary Positive Summary Likelihood Ratios Likelihood Ratios Likelihood Ratios Negative (95% CI)* (95% CI)* (95% CI)† Likelihood Ratios (95% CI) † Dysuria 1.5 (1.2, 2.0) 0.5 (0.3, 0.7) 1.3 (1.2, 1.4) 0.5 (0.4, 0.6) Frequency 1.8 (1.1, 3.0) 0.6 (0.4, 1.0) 1.1 (1.0, 1.2) 0.6 (0.5, 0.7) Hematuria 2.0 (1.3, 2.9) 0.9 (0.9, 1.0) 1.7 (1.3, 2.3) 0.9 (0.8, 0.9) Urgency - - 1.2 (1.1, 1.3) 0.7 (0.6, 0.9) Nocturia - - 1.3 (1.1, 1.6) 0.8 (0.6, 0.9) Fever 1.6 (1.0, 2.6) 0.9 (0.9, 1.0) 1.3 (0.6, 2.6) 1.0 (0.9, 1.0) Flank pain 1.1 (0.9, 1.4) 0.9 (0.8, 1.1) 0.8 (0.7, 1.1) 1.1 (1.0, 1.2) Lower abdominal pain 1.1 (0.9, 1.4) 0.9 (0.8, 1.1) 1.0 (0.9, 1.2) 1.0 (0.9, 1.1) Absence of vaginal discharge 3.1 (1.0, 9.3) 0.3 (0.1, 0.9) - - Absence of vaginal irritation 2.7 (0.9, 8.5) 0.2 (0.1, 0.9) - - Back pain 1.6 (1.2, 2.1) 0.8 (0.7, 0.9) 0.9 (0.7, 1.1) 1.1 (0.9, 1.3) Vaginal discharge on 1.1 (1.0, 1.2) 0.7 (0.5, 0.9) 0.6 (0.5, 0.8) 1.1 (1.0, 1.2) physicalexam Combination of symptoms 1. dysuria and 22.6 frequency present, vaginal discharge and irritation absent 2. dysuria absent, 0.1-0.2 vaginal discharge or irritation present 3. dysuria or frequency 0.3-0.5 present, vaginal discharge or irritation present *Adapted from Bent 2002 †Adapted from Giesen 2010 (diagnostic value at a reference standard threshold of ≥ 102 CFU/ml) 2. What is the best approach in the management of a patient suspected to have AUC? Empiric antibiotic treatment is the most cost-effective approach in the management of AUC. Pre-treatment urine culture and sensitivity is NOT recommended. Standard urine microscopy and dipstick leukocyte esterase (LE) and nitrite tests are not prerequisites for treatment. Strong recommendation, High quality of evidence Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 Summary of Evidence In a andomi ed cont olled t ial CT omen a ed ea s old presenting to primary care with suspected uncomplicated UTI e e andomi ed into fi e mana ement app oaches a empi ic anti iotics i en immediatel empi ic anti iotics sta ted i s mptoms pe sist a te ho s c anti iotics o e ed onl i t o o mo e o the ollo in si ns and s mptoms a e p esent clo d ine smell ine noct ia and d s ia d anti iotics i en i dipstic is positi e o eithe nit ite o le coc tes and t ace o lood and e s mptomatic t eatment initiall then anti iotics ta eted to the specific pathogen when culture results come out. The study concluded that all st ate ies es lted in simila s mptom cont ol ith no si nificant di e ences in se e it o s mptoms o e e s mptoms lasted lon e in patients ho had to ait at least ho s e o e sta tin anti iotics and lon e in those ho aited o the c lt e es lts compared to the immediate antibiotics group. ince the CT on the fi e mana ement app oaches sho ed no si nificant di e ence in s mptom cont ol a cost e ecti eness anal sis as done hich ielded no di e ence in eso ce implications amon the fi e mana ement app oaches It is ecommended that a cost e ecti eness anal sis on the mana ement o UC also e cond cted in the Philippines. 3. Which antibiotics are effective for acute uncomplicated cystitis? Antibiotics recommended for use in AUC are presented in Table 4. Efficacy in terms of clinical cure, cost effectiveness, safety and tolerability were considered in the choice of antibiotics. In addition, the propensity to cause collateral damage and local susceptibility rates were given greater weights in the choice of antibiotic recommendations. Comment: Collateral damage is the “ecological adverse effects” of antibiotic therapy. Such adverse effects include selection of drug- resistant organisms and colonization or infection with multi-drug resistant organisms.12,13 Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  Comment: Collateral damage is the “ecological adverse effects” of antibiotic therapy. Such adverse effects include selection of drug-resistant organisms and colonization or infection with multi-drug resistant organisms.12,13 Table Table 4. Antibiotics 4. Antibiotics that can be usedthat for acutecan be used uncomplicated for acute uncomplicated cystitis cystitis Leading Generic Recommended dose Brand Total Brand Total Antibiotics and duration Unit Price (Php) Unit Price (Php) (Php) (Php) Primary Nitrofurantoin 100 mg BID for 5 days per N/A N/A N/A N/A monohydrate/ orem (PO) macrocrystal (NOT sold locally) Nitrofurantoin 100 mg QID for 5 days PO 53.50/cap 1,070.00 N/A N/A macrocrystals Fosfomycin 3 g single dose PO 477.00/ 477.00 N/A N/A trometamol sachet Alternative Pivmecillinam (NOT 400 mg BID for 3–7 days PO N/A N/A N/A N/A sold locally) Ofloxacin 200mg BID for 3 days PO 53.50/tab 321.00 28.00/tab 168.00 Ciprofloxacin 250mg BID for 3 days PO 32.50/tab 195.00 16.25/tab 97.50 Ciprofloxacin 500mg OD for 3 days PO 49.60/tab 148.80 N/A N/A extended release Levofloxacin 250mg OD for 3 days PO 189.50/ 284.25 49.00/ 73.50 500 mg tab 500 mg tab Norfloxacin 400mg BID for 3 days PO 77.50/tab 465.00 32.50/tab 195.00 Amoxicillin- 625mg BID for 7 days PO 48.90/tab 684.60 29.75/tab 416.50 clavulanate Cefuroxime 250mg BID for 7 days PO 66.50/tab 931.00 36.75/tab 514.50 Cefaclor 500mg TID for 7 days PO 86.00/cap 1,806.00 49.75/cap 1,044.75 Cefixime 200mg BID for 7 days PO 137.50/cap 1,925.00 108.00/tab 1,512.00 Cefpodoxime proxetil 100mg BID for 7 days PO 54.25/tab 759.50 N/A N/A Ceftibuten 200 mg BID for 7 days PO 136.00/tab 1,904.00 N/A N/A ONLY if with Trimethoprim- 160/800 mg BID for 3 days PO 33.75/tab 202.50 17.50/ 105.00 proven sulfamethoxazole Tab susceptibility (TMP-SMX) *Prices listed were taken from the drug prices of Mercury Drug Store as of December 2013 Ampicillin or amoxicillin should NOT be used for empirical treatment given the relatively poor efficacy and the very high prevalence Guidelines of antimicrobial on Diagnosis and Management Part 1 9 resistance of UTI in Adults 2013 Update to these agents worldwide. Strong recommendation, High quality of evidence Summary of Evidence ince the hilippine actice idelines o p in In ectio s iseases I Tas o ce on UTI has not ecommended the use of ampicillin and amoxicillin because of the consistently high resistance rates of E. coli to the said antibiotics see Ta le Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 In the past data on local esistance ates o E. coli was based onl on la o ato s eillance s ch as the epa tment o ealth s ntimic o ial esistance eillance o am ecentl a p ospecti e st d on the p e alence o t imethop im s l ametho a ole resistant E.coli among women with uncomplicated UTI was done in a tertiary hospital in Pasig City. The much lower resistance rates in this study may be due to rigorous inclusion criteria of the study (only p e io sl health mostl p emenopa sal omen ith ncomplicated ac te c stitis and p eloneph itis e e incl ded and a e mo e li el e ecti e o the p e alence o comm nit ac i ed E. coli resistance than hat is epo ted in la o ato ased s eillance no led e o the local antimicrobial susceptibility patterns of E. coli is important in empirical antibiotic selection for uncomplicated UTI. Table 5. Percent Resistance of Urinary E. coli (outpatient urine specimens) Antimicrobial Agent ARSP 2010* ARSP2011** ARSP2012*** AUUTI study 2011+ N=247 N=775 N=988 N=181 TMP-SMX 72 65.8 63.9 41.4 Nitrofurantoin 7.6 11.8 9.8 5.1 Ciprofloxacin 57.4 49 50.6 Levo-5.6 Co-amoxiclav 36.2 27 24.5 11.6 Cefuroxime 59.8 38.9 31.2 5.1 Cefazolin – – – 6.6 Ampicillin 85.4 81.5 – 64.1 Note: *Antimicrobial Resistance Surveillance Program (ARSP), 2010 report 17 **Antimicrobial Resistance Surveillance Program(ARSP), 2011 report 18 *** Antimicrobial Resistance Surveillance Program(ARSP), 2012 report 19 +From a study on uncomplicated UTI in a tertiary hospital in Pasig City 16 T imethop im s l ametho a ole m I o th ee da s sho ld e sed o c lt e p o en s scepti le opatho ens d e to hi h p e alence o local esistance and high failure rates. Strong recommendation, High quality of evidence Summary of Evidence The ole o T in the t eatment o UC has e ol ed in ecent ea s eca se o the chan in landscape in antimic o ial tili ation and conse ent de elopment o esistance In the pdate o the In ectio s iseases ociet o me ica I idelines o the t eatment o ac te ncomplicated c stitis and p eloneph itis T is still conside ed an app op iate a ent o UC as lon as the local esistance ates o opatho ens to T do not e ceed In a andomi ed cont olled t ial o omen ith ac te c stitis Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 clinical c e ates e e si nificantl lo e amon T t eated omen ho had a T non s scepti le isolate compa ed with those who had a susceptible isolate. ence in it o esistance should be considered in choosing an antimicrobial as it correlates with clinical and bacteriologic failures. Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for five days) is recommended as the first line treatment for acute uncomplicated cystitis due to its high efficacy, minimal resistance, minimal adverse effects, low propensity for collateral damage, and reasonable cost. However, the nitrofurantoin monohydrate/macrocrystal formulation is not locally available. Thus, nitrofurantoin macrocrystal formulation 100 mg is recommended, but it should be given four times a day for five days. Strong recommendation, High quality of evidence Summary of Evidence it o antoin a ina t act a ent almost e cl si el emplo ed o t eatment o UC has een sed o mo e than fi e decades o e e its pop la it as hampe ed conce ns a o t e ficac tole ance and the ecommended se en da dosin e imen ecent t ials and meta anal ses sho ed that nit o antoin has compa a le e ficac ith othe anti iotics sed o t eatin UC ith inc easin anti iotic esistance and de elopment o collate al dama e nit o antoin has the ad anta e o lo e esistance ates and less ad e se e ects than the t aditional anti iotics sed o uncomplicated cystitis. it o antoin emained acti e a ainst most opatho ens andomi ed cont olled t ial in sho ed that patients on nit o antoin mac oc stal m I o th ee da s had si nificantl ette clinical and acte iolo ic o tcomes compa ed to placebo. ecent andomi ed cont olled t ial sho ed that a fi e da co se o nit o antoin monoh d ate mac oc stal m I as as e ecti e as a th ee da co se o T do le st en th ta let BID in terms of clinical and microbiologic cure. s stematic e ie of antimicrobial agents used to treat uncomplicated cystitis in women sho ed that sho t te m and lon te m c e o nit o antoin as simila to that o T Compa ed to T nit o antoin had simila ad e se e ent ates ho e e nit o antoin as less li el to ca se ash compa ed ith T This same s stematic e ie sho ed that the nit o antoin o p had hi he sho t te m s mptomatic c e compa ed ith the eta lactams ntimic o ial resistance rates of E.coli urine isolates causing AUC consistently sho ed hi h esistance ates a ainst T hile nit o antoin emained consistentl acti e s E. coli emonst ation o e ficac Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 with reports of low drug resistance based on international and local s scepti ilit patte ns minimal ad e se e ects lo is o collate al dama e and cost e ecti eness ma e nit o antoin an e cellent primary drug of choice for AUC. Fosfomycin (3 g in a single dose) is also a recommended antibiotic for acute uncomplicated cystitis due to its high efficacy, convenience of a single dose, low propensity for collateral damage, good activity against multidrug- resistant uropathogens, and minimal adverse effects. However, there are no local resistance data to date. Strong recommendation, High quality of evidence Summary of Evidence The con enient sin le dose e imen ood in it o acti it a ainst esistant am ne ati e ods and minimal p opensit o collate al dama e ma e os om cin a ational choice T o CTs s ppo ted the use of fosfomycin trometamol for treatment of UTI as its clinical e ficac is compa a le ith othe fi st line a ents a ainst UC In addition a s stematic e ie demonst ated that it has acti it a ainst multidrug resistant pathogens. ecent meta anal sis compa in fosfomycin with other antibiotics showed no difference in clinical s ccess mic o iolo ical s ccess and occ ence o ad e se e ents In act os om cin as s pe io a ainst t imethop im eta lactams and nit o antoin in te ms o mic o iolo ic s ccess Aside om compa a le e ficac the con enience o a sin le dose ma es os om cin a p omisin d o the t eatment o UC o e e local s scepti ilit data is c entl not a aila le on this d Pivmecillinam (400 mg BID for three to seven days) can be used in areas where it is available, as it has reasonable treatment efficacy. However, it is not currently available in the country. Local resistance data is also absent. Strong recommendation, High quality of evidence Summary of Evidence i mecillinam an e tended spect m penicillin and the o al o m o mecillinam has easona le t eatment e ficac o UC eca se o its specificit o the ina t act and minimal p opensit o collate al dama e do le lind CT done in eden concl ded that pi mecillinam as ette than place o in the t eatment o UC nothe CT sho ed that pi mecillinam at m I o th ee da s as as e ecti e as no o acin m I o th ee da s in te ms of early symptomatic cure. In some opean co nt ies its lo Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 esistance ates ha e made pi mecillinam a pop la fi st line choice o UC o e e it is not a aila le in the hilippines Quinolones should NOT be used as a first line drug for acute uncomplicated cystitis despite its efficacy due to the high propensity for collateral damage. Strong recommendation, High quality of evidence Summary of Evidence l o o inolones a e still accepted as hi hl e ficacio s a ents o ac te c stitis o e e the I idelines o the t eatment o ac te ncomplicated c stitis and p eloneph itis pdate eco ni ed the high risk for collateral damage associated with the use of o o inolones The specific ad e se e ects o o o inolones a e in ections ith methicillin esistant S. aureus and increasing o o inolone esistance o am ne ati e acilli the considerations in the Philippine setting include endemic infections s ch as t e c losis and t phoid e e s s ch o o inolones sho ld e conside ed as alte nati e a ents onl and thei se sho ld be limited to cases wherein other agents cannot be used. Beta-lactam agents, including amoxicillin-clavulanate, cefaclor, cefdinir, cefpodoxime proxetil, ceftibuten, and cefuroxime are appropriate choices for therapy when other recommended agents cannot be used. Strong recommendation, High quality of evidence Summary of Evidence eta lactams ha e ene all een p o en in e io in c e ates compared to other agents for treatment of acute uncomplicated c stitis In the pdate o the I idelines on UTI the e ficac ates o eta lactam a ents e e lo e than that o T and o o inolones The post lated mechanism o eta lactam inferiority in the treatment of UTI was related to its lower rate o e adication o a inal opatho ens Th ee CTs di ectl compa ed a eta lactam ith t aditional fi st line a ents The fi st t ial compa ed the e ficac and sa et o ce podo ime p o etil m t ice dail o th ee da s ith T m t ice dail o th ee da s There were no si nificant di e ences in oth clinical and acte iolo ical o tcomes The second st d compa ed amo icillin cla lanate m t ice dail o th ee da s ith cip o o acin m t ice dail o three days in the treatment of uncomplicated cystitis. Clinical and Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 mic o iolo ical c e ates o amo icillin cla lanate e e in e io to that o cip o o acin thi d t ial compa ed ce podo ime p o etil m t ice dail o th ee da s ith cip o o acin m t ice dail o three days in the treatment of acute uncomplicated cystitis. Clinical c e ates o ce podo ime did not each the c ite ia o non in e io it to cip o o acin eta lactams a e also associated ith collate al dama e specificall eme ence o am ne ati e e tended spect m eta lactamase esistance to these a ents s s ch the a e conside ed as alte nati e a ents to e sed hen T o o inolones o nitrofurantoin are contraindicated. 4. What is the effective duration of treatment for acute uncomplicated cystitis? Nitrofurantoin should be given for five days, while fosfomycin is given as a single dose. For the alternative agents: A three day course for fluoroquinolone is recommended. A seven-day regimen for beta-lactams (amoxicillin- clavulanate, cefaclor, cefdinir, cefixime, cefpodoxime proxetil, ceftibuten, and cefuroxime) is recommended. Strong recommendation, High quality of evidence Summary of Evidence One of the reasons why nitrofurantoin was less popular in the past is the ecommended se en da dosin e imen Initial CTs compa in nit o antoin ith place o sed a se en da e imen o e e a andomi ed cont olled t ial done in sho ed that a fi e da t eatment e imen ith nit o antoin had simila clinical e ficac compa ed to a th ee da e imen ith T The Tas o ce the e o e ecommends fi e da d ation o nit o antoin o UC s stematic e ie compa in os om cin ith se e al anti iotics sed sin le dose os om cin and sho ed eithe no si nificant difference between comparators and fosfomycin or some results a o in the se o os om cin e the e o e ecommend a sin le dose o sachet o os om cin o UC hi h alit meta anal sis o t ials ith patients compa ed a th ee da e imen ith a m lti da fi e da s o lon e e imen o t eatment o ncomplicated UTI in omen o si nificant di e ence as noted et een a th ee da e imen and a m lti da e imen in oth sho t te m and lon te m s mptomatic ail e ates o all antimic o ial a ents st died The a ents incl ded in the meta Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 anal sis e e T o o inolones nit o antoin and eta lactams In te ms o oth sho t te m and lon te m acte iolo ical ail e a statisticall si nificant di e ence a o in a m lti da da s e imen as noted o e e in te ms o incidence o ad e se e ents a statisticall si nificant di e ence a o in the th ee da e imen as seen s s ch a th ee da o o inolone e imen as as e ecti e as a da e imen in achie in s mptomatic c e o e e in cases he e acte iolo ical e adication as indicated the lon e d ation o t eatment da s as mo e e ecti e The pdate o the I idelines o the t eatment o ac te ncomplicated c stitis and p eloneph itis also ad ocated a th ee da e imen o o o inolones not onl d e to its e ficac t also d e to the si nificantl hi he ad e se e ent ate o o o inolones This was further compounded by the issues on collateral damage seen ith the se o o o inolones ma in the th ee da e imen mo e appropriate. o eta lactams the e as no si nificant di e ence et een the t o t eatment e imens in the incidence o oth sho t te m and lon term bacteriologic failure. ltho h a th ee da e imen appea ed to e as e ficacio s as a m lti da e imen e en o eta lactams the e ficac ates o this antimic o ial class ha e een conside ed in e io to T o o inolones and nit o antoin This as d e to the lo e ine concent ation o eta lactams and its in e io ability in eradicating E. coli in a inal and ecal ese oi s Th s a se en da e imen is still a anted o eta lactams 5. In elderly women (>65 years) with acute uncomplicated cystitis, what is the effective duration of treatment? In otherwise healthy elderly women with AUC, the recommended duration of treatment is the same as with the general population (See Table 4). Strong recommendation, High quality of evidence Summary of Evidence n pdated Coch ane s stematic e ie that incl ded CTs patients assessed the e ecti eness o sin le dose sho t co se and lon co se antimic o ial e imens in the t eatment o s mptomatic lo e UTI in elde l omen The o tcomes e al ated incl ded pe sistent UTI clinical ail e ad e se eactions and t eatment accepta ilit The e as a statisticall si nificant di e ence in the incidence of persistent UTI in the single dose treatment arm compa ed to oth the sho t co se and lon co se t eatments Compa in sho t co se da s ith lon co se da s Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 t eatment the e as no si nificant di e ence in the incidence o pe sistent UTI clinical ail e and ad e se eactions The e ie s ested that the sin le dose the ap as less e ecti e hile the sho te d ation o the ap as s ficient t eatment o elde l omen ith ncomplicated s mptomatic lo e UTI 6. What should be done for women whose symptoms worsen, do not completely resolve, or do not improve after completion of treatment? Patients whose symptoms worsen or do not improve after completion of treatment should have a urine culture done, and, the antibiotic should be empirically changed pending result of sensitivity testing. Patients whose symptoms fail to resolve after treatment should be managed as complicated UTI. Strong recommendation, Low quality of evidence Summary of Evidence The tas o ce o nd no ne e idence to s ppo t a chan e in the ecommendations om the p e io s ideline atients hose s mptoms o sen o do not imp o e a te the ap ma ha o a esistant patho en This ill e i e a ine c lt e and administ ation o a ne anti iotic pendin es lt o the sensiti it testing. 7. What is the clinical utility of a post-treatment urine culture? Routine post-treatment urine culture and urinalysis in patients whose symptoms have completely resolved are NOT recommended as it does not provide any added clinical benefit. Strong recommendation, Low quality of evidence Summary of Evidence The tas o ce o nd no ne e idence to s ppo t a chan e in the ecommendations om the p e io s ideline In o mal cost enefit anal sis o data om et ospecti e o se ational studies showed that routine screening after treatment was costly pe case detected and p o ided no added clinical enefit A et ospecti e st d on omen t eated o ac te c stitis as done to dete mine hethe o tainin a sin le ollo p ine c lt e ed ced the incidence o s se ent episodes o UTI i t one omen did not ha e a ollo p c lt e hile had post t eatment Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  ine c lt es The t o o ps e e e al ith e a ds to ace eco din o ne ati e int a eno s p elo am UTI p eloneph itis as mptomatic acte i ia o ec ent UTI episodes mptomatic UTI de eloped ithin th ee months in o the no ollo p c lt e o p and o the ollo p c lt e o p mon the omen in the ollo p c lt e o p onl th ee o t o had a positi e c lt e and onl one o these th ee de eloped s mptomatic UTI Algorithm 2. Management of Acute Uncomplicated Cystitis Healthy non-pregnant woman with dysuria, frequency, urgency or hematuria 1 Treat empirically with recommended oral antibiotics (Table 4) 2 Reassess at end of therapy. 3 4 Symptoms YES resolved? No further treatment. NO 5 Do urinalysis, urine culture and change antibiotics empirically pending urine C/S results. Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 References ic el C pecial conside ations in the mana ement o ina t act in ections Inte national Con ess and mposi m e ies ana ement o U ina T act In ections p onald a din Complicated ina t act in ections In ect is Clin o th m illiams U ina t act in ection me in insi hts into app op iate mana ement ost ad ed tamm ooton T ana ement o ina t act in ection in ad lts n l ed in hapi o nd iole T a is tamm al ation o ne anti in ecti e d s o the t eatment o ina t act in ection In ectio s iseases ociet o me ica and the ood and dminist ation Clin In ect is ppl ma a a ats moto T Complicated UTIs e an T ed UTIs In ectiolo ol asel a e pp in In ectio s disease complications o enal t ansplantation idne inte national l iesen Co sins imit o an de aa a ahe T edictin ac te ncomplicated ina t act in ection in omen a s stematic e ie o the dia nostic acc ac o s mptoms and si ns C am act io ed Cent al td an ent allamoth imel ihn aint oes This oman a e an c te Uncomplicated U ina T act In ection ittle oo e T ne ms a ne o es et al ecti eness o fi e di e ent app oaches in mana ement o ina t act in ection andomised cont olled t ial c T ne ittle a te T ne mith ms et al Cost e ecti eness o mana ement st ate ies o ina t act in ections es lts om andomised cont olled t ial c pta ooton T a e llt Col an ille et al Inte national clinical practice guidelines for the treatment of acute uncomplicated cystitis and p eloneph itis in omen pdate the In ectio s iseases ociet o me ica and the opean ociet o ic o iolo and In ectio s iseases Clin In ect is a e ate son Collate al ama e om Cephalospo in o inolone nti iotic The ap Clin In ect is ppl o co e ne Chian C ame o e ho e ficac and a et o a o el nce ail tended elease Cip o o acin Ta let o m lation o T eatment o Uncomplicated U ina T act In ection in omen ntimic o ents Chemothe Tas o ce on U ina T act In ections hilippine actice ideline o p Infectious Disease. The Philippine Clinical Practice Guidelines on the Diagnosis and ana ement o U ina T act In ections in d lts Update e on Cit hilippines I hilippine ociet o ic o iolo and In ectio s iseases an c an co le and ia laa ta amponia enson et al e alence and is acto s o t imethop im s l ametho a ole esistant coli in ncomplicated ina t act in ections in a de elopin co nt oste session p esented at st Inte science Con e ence on ntimic o ial ents and Chemothe ap IC C Chica o Illinois U ia Ca los CC The ntimic o ial esistance eillance o am o ess epo t esea ch Institit e o T opical edicine ntimic o ial esistance eillance o am o ess epo t mma pp ntimic o ial esistance eillance e e ence a o ato ntimic o ial esistance eillance o am nn al epo t pp Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  pta ooton T o e ts tamm ho t co se nit o antoin o the t eatment o ac te ncomplicated c stitis in omen ch Inte n ed o almano ici T estio ean een a l aphe ei o ici ntimic o ial agents for treating uncomplicated urinary tract infection in women. Cochrane ata ase st e C Ch istiaens TC e ee e e sch ae en ee sman e tens aesenee e andomised cont olled t ial o nit o antoin e s s place o in the treatment of uncomplicated urinary tract infection in adult women. Br J Gen act inassian a e is a Chattopadh a o ill c o th illiams compa ison et een sin le dose os om cin t ometamol on il and a da co se o t imethop im in the t eatment o ncomplicated lo e ina t act in ection in omen Int ntimic o ents p tein Compa ison o sin le dose os om cin and a da co se o nitrofurantoin in female patients with uncomplicated urinary tract infection. Clinical the ape tics o ala as asto is C apas elis a a eo opo los os om cin o the t eatment o m ltid esistant incl din e tended spect m eta lactamase p od cin nte o acte iaceae in ections a s stematic e ie ancet In ect is lse ie td an ala as o lo mano To ias a adima apas elis a ailidis I et al os om cin e s s othe anti iotics o the t eatment o c stitis a meta anal sis o andomi ed cont olled t ials ntimic o Chemothe ep e a olm tenl nd ndholm onsen T Clinical and acte iolo ical o tcome o di e ent doses and d ation o pi mecillinam compared with placebo therapy of uncomplicated lower urinary tract infection in omen the UTI p o ect cand im ealth Ca e a icolle adsen e eec lochlin e o ild et al Th ee da s o pi mecillinam o no o acin o t eatment o ac te ncomplicated ina in ection in omen cand In ect is an a atha iama ello le io lacho iannis entea o adinos T et al Ce podo ime o etil e s s T imethop im l ametho a ole o ho t Te m The ap o Uncomplicated c te C stitis in omen ntimic o ents Chemothe ooton T choles pta tapleton o e ts tamm mo icillin cla lanate s cip o o acin o the t eatment o ncomplicated c stitis in omen a andomi ed t ial e ooton T o e ts tapleton Ce podo ime s cip o o acin o sho t co se t eatment o ac te ncomplicated c stitis a andomi ed t ial e ilo atchman a l Ch istiaens T ae heim ei o ici ation of antibacterial treatment for uncomplicated urinary tract infection in women. Coch ane ata ase st e C tte s o t e ie nti iotic d ation o t eatin ncomplicated symptomatic lower urinary tract infections in elderly women. Cochrane Database st e C a C ell ic ne al ation o s spected ina t act in ection in am lato omen a cost tilit anal sis o o fice ased st ate ies am act inic o ilne I all aa e T a nett U ine c lt e a te t eatment o ncomplicated c stitis in omen o th ed ch lt cCa e e sT o e a T c te c stitis a p ospecti e st d o la o ato tests and d ation o the ap a o Clin oc 7. Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  ACUTE UNCOMPLICATED PYELONEPHRITIS IN WOMEN Section Summary efinition o ac te ncomplicated p eloneph itis U AUP is suspected in otherwise healthy women with no clinical o histo ical e idence o anatomic o nctional olo ic a no malities ho p esent ith the classic s nd ome o e e T C chills an pain costo e te al an le tende ness na sea and omitin ith o itho t si ns and s mptoms o lower UTI. a o ato findin s incl de p ia C o cent i ed ine on inal sis and acte i ia ith co nts o C U m on ine c lt e Strong recommendation, Moderate quality of evidence e t eatment dia nostic tests Urinalysis and Gram stain are recommended. Urine culture and sensiti it test sho ld also e pe o med o tinel to acilitate cost e ecti e se o antimic o ial a ents and eca se o the potential o se io s se elae i an inapp op iate antimic o ial agent is used. t on ecommendation ode ate alit o e idence Blood cultures are NOT routinely recommended except in patients with signs of sepsis. Strong recommendation, High quality of evidence Biomarkers ioma e s p ocalcitonin mid e ional p o at ial nat i etic peptide C eacti e p otein a e T ecommended since the are not clinically useful in determining the need for admission o in p edictin ad e se o tcomes s ch as ec ence and p olon ed hospitali ation Strong recommendation, Low quality of evidence Indications for admission The ollo in a e the indications o admission Ina ilit to maintain o al h d ation o ta e medications Conce n a o t compliance esence o possi le complicatin conditions e e e illness ith hi h e e se e e pain ma ed de ilit and signs of sepsis Strong recommendation, Moderate quality of evidence Antibiotic treatment e e al e imens o nd to e e ecti e in U a e listed in Ta le Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  ima d s o choice and alte nati e d s a e p esented ficac cost e ecti eness sa et tole a ilit local s scepti ilit and propensity for collateral damage were considered for the choice of the antibiotic. The aminopenicillins ampicillin o amo icillin and fi st ene ation cephalosporins are NOT recommended because of the high p e alence o esistance and inc eased ec ence ates in patients i en these eta lactams Strong recommendation, Moderate quality of evidence eca se o hi h esistance ates to T this d is T recommended for empiric treatment but can be used when the organism is found to be susceptible on urine culture and sensiti it Strong recommendation, Moderate quality of evidence inolones a e ecommended as the fi st line t eatment o ac te ncomplicated p eloneph itis not e i in hospital admission Strong recommendation, High quality of evidence In patients not e i in hospital admission an initial sin le I IM dose of ceftriaxone or aminoglycoside may be considered ollo ed an o the o al anti iotics in Ta le Strong recommendation, Moderate quality of evidence o patients ith ac te ncomplicated p eloneph itis e i in hospitali ation ce t ia one o o inolones o amino l cosides a e ecommended as empi ic fi st line t eatment Strong recommendation, Moderate quality of evidence Int a eno s anti iotics can e shi ted to an o the listed o al antibiotics once the patient is afebrile and can tolerate oral drugs. The choice of continued antibiotic therapy should be guided by the ine c lt e and sensiti it es lts once a aila le Strong recommendation, Moderate quality of evidence o s spected ente ococcal in ection ampicillin ma e com ined with an aminoglycoside. Weak recommendation, Low quality of evidence Ca apenems and pipe acillin ta o actam sho ld e ese ed o ac te p eloneph itis ca sed m lti d esistant o anisms that are susceptible to either drug. Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 Duration of treatment The recommended duration of t eatment is da s elected o o inolonescan e i en o da s Strong recommendation, High quality of evidence ole o adiolo ic ima in o tine olo ic e al ation and o tine se o ima in procedures are NOT recommended. Strong recommendation, Moderate quality of evidence Conside ea l adiolo ic e al ation i the patient has a histo o olithiasis ine p o enal ins ficienc Strong recommendation, Moderate quality of evidence Conside adiolo ic e al ation i the patient emains e ile ithin ho s o t eatment o i s mptoms ec to le o t the p esence o neph olithiasis ina t act o st ction enal o pe ineph ic a scesses o othe complications o p eloneph itis Weak recommendation, Low quality of evidence Obtain urologic consultation if workup shows abnormalities. Weak recommendation, Low quality of evidence ollo p la o ato tests In patients who are clinically responding to therapy (usually appa ent in ho s a te initiation o t eatment a ollo p urine culture is NOT necessary. Weak recommendation, Low quality of evidence o tine post t eatment c lt es in patients ho a e clinicall imp o ed a e also not ecommended Weak recommendation, Low quality of evidence In omen hose s mptoms do not imp o e d in the ap and in those hose s mptoms ec a te t eatment a epeat ine c lt e and sensiti it test sho ld e pe o med Weak recommendation, Low quality of evidence ec ence o s mptoms ec ence o s mptoms e i es anti iotic t eatment ased on ine c lt e and sensiti it test es lts in addition to assessin for underlying genitourologic abnormality. Weak recommendation, Low quality of evidence The d ation o e t eatment in the a sence o a olo ic abnormality is two weeks. Weak recommendation, Low quality of evidence Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  o patients hose s mptoms ec and hose c lt e sho s the same o anism as the initial in ectin o anism a o to si ee e imen is ecommended Weak recommendation, Low quality of evidence Recommendations and Summary of Evidence 1. When is AUP suspected? AUP is suspected in otherwise healthy women with no clinical or historical evidence of anatomic or functional urologic abnormalities, who present with the classic syndrome of fever (T≥38°C), chills, flank pain, costovertebral angle tenderness, nausea and vomiting, with or without signs and symptoms of lower UTI.1 Laboratory findings include pyuria (≥5 WBC/HPF of centrifuged urine) on urinalysis and bacteriuria with counts of ≥10,000 CFU/mL on urine culture.2 Strong recommendation, Moderate quality of evidence Summary of Evidence Acute pyelonephritis usually occurs in otherwise healthy women; ho e e in o mation e a din is acto s o p eloneph itis is limited In a pop lation ased case cont ol st d o omen ith p eloneph itis to ea s o a e the acto s associated ith p eloneph itis is ee e enc o se al inte co se in the p e io s da s odds atio CI o times pe ee ecent UTI CI dia etes CI ecent incontinence CI ne se al pa tne in the p e io s ea CI ecent spe micide se CI and UTI histo in the pa ticipant s mothe CI 2. What are the recommended diagnostic tests for acute uncomplicated pyelonephritis? Urinalysis and Gram stain are recommended. Urine culture and sensitivity test should also be performed routinely to facilitate cost-effective use of antimicrobial agents and because of the potential for serious sequelae if an inappropriate antimicrobial agent is used. Strong recommendation, Moderate quality of evidence Blood cultures are NOT routinely recommended except in patients with signs of sepsis. Strong recommendation, High quality of evidence Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  ote i ns o sepsis as desc i ed in the p e io s ideline incl de the p esence o an t o o the ollo in Tempe at e o Co o C e openia C o le oc tosis C Tach ca dia eats min Tachp nea min o aC mm potension mm o mm d op om baseline) Summary of Evidence In a et ospecti e st d in o ea a p ospecti e data ase o omen ith p eloneph itis as anal sed to const ct and alidate a model that aimed to p edict acte emia and di ect the p ope se o lood c lt es The ollo in e e identified as independent is acto s o acte emia a e ea s omitin hea t ate eats min se mented ne t ophils and ine C ei hts e e assi ned to each acto total sco e o and the model st atified patients into ha in lo to inte mediate to o hi h to is o acte emia In concl sion the said model as help l in assessing the need for blood cultures and the need for hospital admission o int a eno s anti iotic administ ation in patients ith uncomplicated pyelonephritis. Blood cultures contribute to the management of acute pyelonephritis when the blood culture results are discordant with the results of the ine c lt e p ospecti e o se ational m lticente coho t st d determined the risk factors for bacteremia with a uropathogen that as not c lt ed o eco ni ed in the ine e al a le patients e e ine c lt e positi e and e e positi e o acte emia i e pe cent o the lood c lt es e e disco dant ith the ine c lt e The p esence o a ina cathete CI mali nanc CI and acti e antimic o ial UTI t eatment CI e e statisticall si nificant acto s associated ith disco dant es lts The mo talit ates a te a da ollo p e e as ollo s o e all ate patients ith disco dant es lts s patients ith conco dant es lts is atio CI o e e the p esence o ina cathete and acti e antimic o ial UTI t eatment are characteristics of complicated UTI. In a p ospecti e st d elasco et al 7 he e the anal ed the data o omen olde than ea s old onl o the omen had disco dant c lt e es lts odification o initial anti iotic therapy based on culture results was not needed. There was also Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 no di e ence in the clinical e ol tion o the in ection in oth the discordant and the nondiscordant groups. The study concluded that blood cultures may not be routinely needed.7 3. Can biomarkers help determine which patients can be treated as outpatients, or which patients will have adverse outcomes? Biomarkers (procalcitonin, mid-regional pro-atrial natriuretic peptide, C-reactive protein) are NOT recommended since they are not clinically useful in determining the need for admission or in predicting adverse outcomes such as recurrence and prolonged hospitalization. Strong recommendation, Low quality of evidence Summary of Evidence m lticente p ospecti e o se ational st d in eme enc depa tments in ance e al ated consec ti e patients to assess the e ecti eness o p ocalcitonin CT mid e ional p o at ial nat i etic peptide and C eacti e p otein C measurements in guiding emergency physicians on deciding if a patient with acute pyelonephritis should be admitted to the hospital. e o mance cha acte istics e e tested o a io s c t o s o C CT and The li elihood atios e e not clinicall ele ant hate e the ioma e o th eshold The st d concl ded that none o these th ee ma e s co ld elia l help ph sicians in thei decision making process. nothe ench st d e al ated the disc iminato po e and p edicti e acc ac o p ocalcitonin o ad e se o tcomes in patients ith ac te p eloneph itis ineteen pe cent o patients anal ed had ad e se medical o tcomes hich incl ded a pe cei ed need o hospitali ation p esence o se e e sepsis defined the p esence o concomitant s stemic in ammato esponse and o an d s nction ent olo ic s ical p oced es elated to p eloneph itis e idence o enal a scess admission to intensi e ca e s se ent hospitali ation and p eloneph itis elated death ocalcitonin a ied idel and altho h the median le el as hi he in patients ith ad e se medical o tcomes compa ed ith those itho t ad e se medical o tcomes the di e ence as not statisticall si nificant n m s n m p The e was no useful threshold that could accurately discriminate between the two groups. The tilit o p ocalcitonin in p edictin acte emia as e al ated in a p ospecti e o se ational m lticente coho t st d o ad lts Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  ith e ile UTI sin le p ocalcitonin le el had the est dia nostic pe o mance in p edictin the p esence o acte emia sensiti it CI specificit CI The use of this biomarker decreased the number of blood cultures ta en t still ena led identification o to o patients ith acte emia This t anslated to cost sa in s o the patients o e e lood c lt es a e ecommended to e ta en p io to the initiation o anti iotics aitin o the es lts o p ocalcitonin le els to dete mine hich patients o ld e i e lood c lt es o ld es lt in inappropriate delay in treatment. The se o C eacti e p otein as a ma e o p olon ed hospitali ation and U ec ence as anal ed in consec ti e patients in si di e ent instit tes in o th o ea imple lo istic e ession anal sis e ealed that the e as a si nificant co elation et een the C le el at discha e and ec ence o ac te p eloneph itis p The e as eate incidence o ec ence in patients ith C m d at discha e compa ed ith patients ith C m d p atients ith a ma imal C o m d d in admission on the othe hand had lon e hospitali ation sta s compa ed to patients ith ma imal C m d p The need o int a eno s anti iotic the ap in these patients as eate p The clinical tilit o no in that patients ith ce tain C le els ha e a hi he ec ence ate o ha e p olon ed hospitali ation emains unclear. eca se o the limited a aila ilit limited clinical tilit and the cost o these ioma e s especiall in eso ce limited settin s o tine use of biomarkers in the management of AUP is not recommended. 4. What are the indications for admission in patients with acute uncomplicated pyelonephritis? The following are the indications for admission: Inability to maintain oral hydration or take medications; Concern about compliance; Presence of possible complicating conditions; Severe illness with high fever, severe pain, marked debility, and signs of sepsis Strong recommendation, Moderate quality of evidence Summary of Evidence The e a e no ne CTs di ectl compa in inpatient s o tpatient mana ement o e e in the m lticente do le lind andomi ed non in e io it st d la sne et al compa in a fi e da co se o le o o acin m ith a da co se o cip o o acin m Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  Presence of possible complicating conditions; Severe illness with high fever, severe pain, marked debility, and signs of sepsis Strong recommendation, Moderate quality of evidence I most Summary o the s ects e e t eated ith o al anti iotics Patients of Evidence ithareac There no newte RCTs p eloneph itis inpatient directly comparing incl vs.dinoutpatient ones ith However, management. acte emia ee in the multicenter, treated in double-blind, the community randomized and non-inferiority study demonstrated by Klausner et al. comparinghigh microbiologic a five-day and course of levofloxacin 750 clinical mg OD withsa ccess ates 10-day course ith oth of ciprofloxacin 500lemgoBID,o most acinof and cip owere the subjects o treated acin with Thisoral showed antibiotics. 12 that patients with AUP can be safely treated as outpatients Patients with acute pyelonephritis, including ones with bacteremia, were treated in the community ith anti and demonstrated iotics that ha e high microbiologic ood o and clinical al rates success ioa withaila bothilit levofloxacin and ciprofloxacin. This showed that patients with AUP can be safely treated as outpatients with antibiotics that have good oral 5. What drugs can be used for empiric treatment of acute bioavailability. uncomplicated pyelonephritis? 5. What drugsSeveral can be usedregimens found of for empiric treatment toacute be uncomplicated effective inpyelonephritis? AUP are listed in Table 6. Primary drugs of choice and alternative drugs are Several regimens found to be effective in AUP are listed in Table 6. Primary drugs of choice presented. Efficacy, cost effectiveness, safety, tolerability, and alternative drugs are presented. local susceptibility, andEfficacy, cost effectiveness, propensity safety, tolerability, for collateral damage local susceptibility, and propensity for were considered forcollateral the choicedamage of werethe considered for the choice of the antibiotic. antibiotic. Table6. 6. Table Empiric Empiric treatment treatment regimensregimens for acute uncomplicated for acute uncomplicated pyelonephritis pyelonephritis Antibiotic Dose, Frequency and Duration ORAL Primary Ciprofloxacin 500 mg BID for 7-10 days Ciprofloxacin extended release 1000 mg OD for 7 days Levofloxacin 250 mg OD for 7-10 days 750 mg OD for 5 days Ofloxacin 400 mg BID for 14 days Alternative Cefixime 400 mg OD for 14 days Ceftibuten 400 mg OD for 14 days Cefuroxime 500 mg BID for 14 days Co-amoxiclav (when GS shows gram-positive orgs) 625 mg TID for 14 days PARENTERAL (given until patient is afebrile) Primary Ceftriaxone 1-2 g q24 hours Ciprofloxacin 400 mg q12 hours Levofloxacin 250-750 mg q24 hours Ofloxacin 200-400 mg q 12 hours Amikacin 15 mg/kg BW q 24 hours Gentamicin +/- ampicillin 3-5 mg/kg BW q24 hours Alternative Ampicillin-sulbactam (when GS shows gram- 1.5 g q6 hours positive orgs Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 23 Reserved for Ertapenem (if ESBL prevalence > 10%) 1 g q24 hours MDROs Piperacillin-tazobactam 2.25-4.5 g q6-8 hours The aminopenicillins (ampicillin or amoxicillin) and first generation cephalosporins are NOT recommended because of the high prevalence of resistance and increased recurrence rates in patients given these Guidelines beta-lactams. on Diagnosis and Management of UTI in Adults 2013 Update Part 1 Strong recommendation, Moderate quality of evidence  The aminopenicillins (ampicillin or amoxicillin) and first generation cephalosporins are NOT recommended because of the high prevalence of resistance and increased recurrence rates in patients given these beta-lactams. Strong recommendation, Moderate quality of evidence Because of high resistance rates to TMP-SMX, this drug is NOT recommended for empiric treatment but it can be used when the organism is found to be susceptible on urine culture and sensitivity. Strong recommendation, Moderate quality of evidence Quinolones are recommended as the first line treatment for acute uncomplicated pyelonephritis not requiring hospital admission. Strong recommendation, High quality of evidence In patients not requiring hospital admission, an initial single IV/IM dose of ceftriaxone or aminoglycoside may be considered followed by any of the oral antibiotics in Table 6. Strong recommendation, Moderate quality of evidence For patients with acute uncomplicated pyelonephritis requiring hospitalization, ceftriaxone, fluoroquinolones, or aminoglycosides are recommended as empiric first-line treatment. Strong recommendation, Moderate quality of evidence Intravenous antibiotics can be shifted to any of the listed oral antibiotics once the patient is afebrile and can tolerate oral drugs. The choice of continued antibiotic therapy should be guided by the urine culture and sensitivity results once available. Strong recommendation, Moderate quality of evidence For suspected enterococcal infection, ampicillin may be combined with an aminoglycoside. Weak recommendation, Low quality of evidence Carbapenems and piperacillin-tazobactam should be reserved for acute pyelonephritis caused by multi-drug resistant organisms that are susceptible to either drug. Strong recommendation, Moderate quality of evidence Summary of Evidence The e e e no andomi ed clinical t ials on t eatment o U solel All of the studies included males and complicated UTI. Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 Ciprofloxacin and extended-release Ciprofloxacin ne andomi ed do le lind t ial compa ed the e ficac o m o e tended elease cip o o acin Cip o once dail ith cip o o acin m t ice dail each i en o da s in patients with complicated UTI or acute pyelonephritis. The clinical and acte iolo ic c e ates did not di e si nificantl The ates o ad e se e ents e e simila Levofloxacin vs. ciprofloxacin m lticente do le lind andomi ed non in e io it t ial compa ed le o o acin m I dail o fi e da s ith cip o o acin m I and o m I o da s in patients ith U and complicated UTI. o p anal sis o the patients ith U sho ed that mic o iolo ical e adication as achie ed in o the le o o acin t eated patients and o cip o o acin t eated patients in the modified intention to t eat ITT pop lation In the mic o iolo icall e al a le pop lation o the le o o acin t eated s ects s o the cip o o acin t eated s ects achie ed mic o iolo ic e adication Clinical s ccess as achie ed in o le o o acin t eated s ects in the ITT pop lation s in the cip o o acin t eated s ects In the pop lation clinical s ccess as achie ed in o the le o o acin t eated s cip o o acin t eated s ects Ertapenem vs. ceftriaxone com ined anal sis o t o andomi ed do le lind m lticente trials compa in e tapenem once a da ith ce t ia one once a da ollo ed app op iate o al the ap a te da s o pa ente al the ap sho ed that o e tapenem t eated and o ce t ia one t eated mic o iolo icall e al a le ac te p eloneph itis patients achie ed mic o iolo ical esponse at completion o pa ente al the ap t test o c e o e tapenem t eated patients s o ce t ia one t eated patients had mic o iolo ic esponse d e se e ents e e also simila in oth st d o ps TMP-SMX resistance E. coli is the most p e alent patho en o ncomplicated UTI Inc easin T esistance ma es this anti iotic a poo choice o U In a ecent s eillance st d done in ni e sit a filiated eme enc depa tments in the United tates o me ica om T esistance as o nd to e app o imatel Fluoroquinolone resistance In the same st d in ni e sit a filiated eme enc depa tments in the United tates mentioned ea lie o o inolone esistance Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  as The I ideline ecommended an initial one time int a eno s dose o a lon actin pa ente al antimic o ial s ch as o ce t ia one o a consolidated h dose o an amino l coside i the p e alence o o o inolone esistance e ceeds This ecommendation e i ed an acc ate no led e o the p e alence o esistance in the st died pop lation The ntimic o ial esistance eillance o am ata hich consolidated the pe cent resistance of urinary E. coli from different regional hospitals in the hilippines epo ted cip o o acin esistance o o e e this ma not e ep esentati e o the t e p e alence o esistance in the community since the E. coli isolates were submitted from o e nment hospitals and not limited to patients ith ncomplicated UTI p ospecti e coho t on ac te ncomplicated UTI incl din ac te p eloneph itis om a p i ate te tia hospital in asi Cit epo ted o o inolone esistance p e alence o less than i en the lac o elia le epidemiolo ic data on the p e alence o o o inolone esistance amon opatho ens no led e o is acto s o o o inolone esistance ma aid in the selection o initial antibiotics for acute pyelonephritis. A nested case–control study within a cohort study of adults with febrile UTI seen in primary healthcare centers or emergency departments in the Netherlands found that ecent hospitali ation ina cathete and o o inolone se in the past si months e e independent is acto s o o o inolone esistance in comm nit onset e ile UTI ca sed E. coli. Extended spectrum beta lactamase producing E. coli In a et ospecti e coho t st d in o ea e tended spect m eta lactamase production in E. coli isolates as in comm nit associated ac te p eloneph itis s in healthca e associated ac te p eloneph itis p In a p ospecti e coho t o patients ith UC and U om a te tia hospital in asi Cit E. coli as the most common opatho en isolated comp isin o isolates ith ate o p od ction o t o E. coli isolates causing uncomplicated UTI. ltiple st dies ha e so ht to dete mine the p e alence ate o comm nit ac i ed UTIs ca sed p od cin o anisms et ospecti e st d in it e land o nd that amon patients ith UTI d e to p od cin E. coli had comm nit ac i ed UTI and had healthca e associated UTI esistance ates o commonl sed anti iotics in comm nit ac i ed isolates e e as ollo s amo icillin cla lanic acid esistance cip o o acin esistance no o acin esistance t imethop im s l ametho a ole esistance nit o antoin esistance Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 and os om cin esistance It should be noted that these isolates ha e hi h esistance to commonl sed antimic o ials e cept o nitrofurantoin and fosfomycin. In a et ospecti e st d o patients ith acte emic UTIs m ltiple lo istic e ession anal sis sho ed that male ende CI and healthca e acilit esidenc CI e e independent is acto s o p od cin in ections mon patients ith UTI in o ea e e in ected ith p od cin acte ia and the is o s ch an in ection as t ice hi he in inpatient UTI The m lti a iate anal sis sho ed that the ollo in e e clinicall si nificant is acto s o p od cin opatho ens inpatient o i in CI p e io s hospitali ation CI emale se CI ole cathete i ation CI e pos e to ce aclo CI and e pos e to ce mino CI nothe p ospecti e st d sho ed an positi it ate o in ncomplicated UTIs and in complicated UTIs p lti a iate anal sis sho ed that the ollo in ee associated ith positi e E. coli ha in mo e than th ee ina t act in ection episodes in the p ecedin ea CI se o a eta lactam anti iotic in the p ecedin th ee months CI and p ostatic disease CI n the othe hand anothe case cont ol st d done in painsho ed that amon di e ent acto s st died onl p e io s e pos e to second ene ation cephalospo ins as st on l associated ith p od cin E. coli a te m lti a iate anal sis CI Patients presenting with acute p eloneph itis ith is acto s o p od cin o anisms ma enefit om ea l initiation o the ap e ecti e o these o anisms 6. What is the effective duration of treatment for AUP? The recommended duration of treatment is 14 days. Selected fluoroquinolones can be given for 7-10 days. Strong recommendation, High quality of evidence Summary of Evidence The standa d ecommended d ation o t eatment o U is da s o e e in an e a o inc easin anti iotic esistance sho t co ses of antibiotics are preferred. The UTI T t ial an ie oop et al is an on oin andomi ed place o cont olled do le lind m lticente non in e io it t ial on Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1  patients in the ethe lands ith comm nit ac i ed e ile UTI It compa ed se en da s o cip o o acin o se en da s o empi ical lactam entamicin I ith ea l s itch to o al cip o o acin ollo ed se en da s o place o sho t t eatment a m s se en da s o cip o o acin o se en da s o empi ical lactam entamicin I ith ea l s itch to o al cip o o acin ollo ed se en da s o linded cip o o acin hich ep esented the standa d da t eatment a m In the st d ete son et al le o o acin m i en o fi e da s had simila e ficac ates to cip o o acin I m I i en o da s ecent p ospecti e non in e io it t ial compa in the e ficac o cip o o acin o da s s da s in omen ith comm nit ac i ed U concl ded that ac te p eloneph itis in omen incl din olde omen and those ith mo e se e e in ection can e t eated s ccess ll and sa el ith o al cip o o acin o se en days. Th s in a sta le patient dia nosed ith U itho t an cont aindication a se en da d ation o t eatment ith selected inolones can e sed 7. Who will require work up for urologic abnormalities? Routine urologic evaluation and routine use of imaging procedures are NOT recommended. Strong recommendation, Moderate quality of evidence Consider early radiologic evaluation if the patient has a history of urolithiasis, urine pH ≥ 7.0 or renal insufficiency. Strong recommendation, Moderate quality of evidence Consider radiologic evaluation if the patient remains febrile within 72 hours of treatment or if symptoms recur to rule out the presence of nephrolithiasis, urinary tract obstruction, renal or perinephric abscesses, or other complications of pyelonephritis. Weak recommendation, Low quality of evidence Obtain urologic consultation if workup shows abnormalities. Weak recommendation, Low quality of evidence Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 Summary of Evidence ecommendations e a din urologic e al ation ha e een ased mostl on e pe t opinion and small sin le cente o se ational st dies p ospecti e o se ational st d on ad lt patients ith febrile UTI in eight emergency departments in the Netherlands sought to de elop a clinical le to help asce tain the need o adiolo ic ima in In the m lti a iate anal sis the ollo in p edicto s e e si nificantl associated ith the findin o a clinicall ele ant olo ic diso de histo o olithiasis ine p and enal ins ficienc lome la filt ation ate ased on modification o diet in enal disease o m la m min m ). The prediction rule incl ded these th ee a ia les ith one point assi ned o each In the de i ation coho t n ith a c t o point o point the ne ati e p edicti e al e o an clinical ele ant adiolo ic findin as positi e p edicti e al e as sensiti it as and the specificit as In the alidation coho t n the as and as o clinicall ele ant adiolo ic findin s The estimated a elati e ed ction o in adiolo ic ima in i the p ediction le as sed The median d ation o e e as t o da s in this st d ation o e e da s as not associated ith an clinicall ele ant adiolo ic findin ni a iate CI 8. Is a follow-up urine culture recommended? In patients who are clinically responding to therapy (usually apparent in 100,000 CFU/mL of the same uropathogen in two consecutive midstream urine specimens or ≥100 CFU/mL of a single uropathogen in one catheterized urine specimen. Symptoms attributable to urinary infection should be absent. Strong recommendation, High quality of evidence In settings where obtaining two consecutive urine cultures is not feasible, or is difficult, one urine culture is an acceptable alternative for the diagnosis of ASB in pregnancy. Weak recommendation, Low quality of evidence Guidelines on Diagnosis and Management of UTI in Adults 2013 Update Part 1 Summary of Evidence The tas o ce o nd no ne e idence that would merit a change in the ecommendations om the p e io s ideline In the update of the Philippine Clinical Practice Guidelines on the Diagnosis and ana ement o U ina T act In ections in d lts acte i ia as defined as acte ial co nts o C U m in t o consec ti e ine specimens ased on in et al Nicolle et al. in cited ass in hich noted that in o cases in ce tain as mptomatic o ps a acte ial co nt o C Um in a midst eam clean catch ine specimen can e confi med a concomitant co nt in a cathete i ed specimen n the othe hand lo e acte ial co nts e e not s all confi med the cathete i ed specimen. A second