uti Urogenital Tract Infection Urogenit Tract Infect 2465-8243 2465-8510 Korean Association of Urogenital Tract Infection and Inflammation 10.14777/uti.2017.12.02.55 uti-12-55 Review The Clinical Guidelines for Acute Uncomplicated Cystitis and Acute Uncomplicated Pyelonephritis KimKi Ho KimJae Heon 1 LeeSeung-Ju 2 ChungHong 3 ChungJae Min 4 JungJae Hung 5 ChoeHyun Sop 2 ChoiHun 6 LeeSun-Ju 7 The Committee of The Korean Association of Urogenital Track Infection and Inflammation Department of Urology, Dongguk University College of Medicine, Gyeongju Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul Department of Urology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon Department of Urology, Konkuk University Chungju Hospital, Konkuk University School of Medicine, Chungju Department of Urology, Pusan National University Yangsan Hospital, Yangsan Department of Urology, Yonsei University Wonju College of Medicine, Wonju Department of Urology, Korea University Ansan Hospital, Ansan Department of Urology, Kyung Hee University School of Medicine, Seoul, Korea Correspondence to: Ki Ho Kim http://orcid.org/0000-0001-8532-6517 Department of Urology, Dongguk University College of Medicine, 87 Dongdae-ro, Gyeongju 38067, Korea Tel: +82-54-770-8525, Fax: +82-54-770-8503 E-mail: honda400uro@gmail.com 082017 19082017 12255 64 10042017 25042017 25042017 Copyright © 2017 Korean Association of Urogenital Tract Infection and Inflammation 2017 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

To date, there has not been an establishment of guidelines for urinary tract infections, due to limited domestic data in Korea, unlike other North American and European countries. The clinical characteristics, etiology, and antimicrobial susceptibility of urinary tract infections vary from country to country. Moreover, despite the same disease, antibiotic necessary to treat it may vary from country to country. Therefore, it is necessary to establish a guideline that is relevant to a specific country. However, in Korea, domestic data have been limited, and thus, guidelines considering the epidemiological characteristics pertaining specifically to Korea do not exist. Herein, describe a guideline that was developed by the committee of The Korean Association of Urogenital Tract Infection and Inflammation, which covers only the uncomplicated urinary tract infections, as covering all parts in the first production is difficult.

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Algorithm for clinical treatment of acute uncomplicated pyelonephritis. TMP-SMX: trimethoprim-sulfamethoxazole.

Algorithm for clinical management of acute uncomplicated cystitis (AUC). UTI: urinary tract infection, ESBL: extended spectrum beta-lactamase, TMP-SMX: trimethoprim-sulfamethoxazole.

Empirical antibiotic therapy for acute uncomplicated cystitis

Antibiotic Daily dose (oral) Duration of therapy (d)
Fosfomycin trometamol 3 g qd 1
Pivmecillinama) 400 mg tid 3
Nitrofurantoin macrocrystala) 100 mg bid 5-7
-Lactams    
  Amoxicillin-clavulanic acid 250/125 mg tid 7
500/125 mg bid  
  Cefaclor 250 mg tid 7
  Cefdinir 100 mg tid 5-7
  Cefcapene pivoxil 100 mg tid 5-7
  Cefpodoxime prexetil 100 mg bid 5-7
Fluoroquinolones    
  Ciprofloxacinb) 500 mg bid 3
  500 mg SR qd  
  Tosufloxacinb) 150 mg bid 3

qd: once a day, tid: three times a day, bid: twice a day, SR: sustained-release.

April 2016, not available in Korea,

not available for pregnant women.

Factors that suggest a potential acute complicated pyelonephritis [23]

The presence of an indwelling catheter, stent or splint (urethral, ureteral, renal) or the use of intermittent bladder catheterisation
Post-void residual urine of ＞100 ml
An obstructive uropathy of any aetiology, e.g., bladder outlet obstruction (including neurogenic urinary bladder), stones and tumor
Vesicoureteric reflux or other functional abnormalities
Urinary tract modifications, such as an ileal loop or pouch
Chemical or radiation injuries of the uroepithelium
Peri- and postoperative urinary tract infection
Renal insufficiency and transplantation, diabetes mellitus and immunodeficiency

Initial therapy recommended for severe acute uncomplicated pyelonephritis

Initial therapy LE GR
A parenteral fluoroquinolone, in communities with Escherichia coli fluoroquinolone-resistance rates ＜10%. 1b B
A third-generation cephalosporin, in communities with ESBL-producing E. coli resistance rates ＜10%. 1b B
An aminopenicillin plus a -lactamase-inhibitor in cases of known susceptible Gram-positive pathogens. 4 B
An aminoglycoside or carbapenem in communities with fluoroquinolone and/or ESBLs-producing E. coli resistance rates ＞10%. 1b B

LE: level of evidence, GR: grade, ESBL: extended spectrum beta-lactamase.

Initial empirical antimicrobial therapy in acute uncomplicated pyelonephritis in premenopausal women (oral therapy: mild and moderate acute uncomplicated pyelonephritis)

Antibiotics Daily dose Duration of therapy (d) Reference
Ciprofloxacina) 500-750 mg bid 7-10 Talan et al. [35]
Levofloxacina) 250-500 mg qd 7-10 Richard et al. [41]
Levofloxacin 750 mg qd 5 Klausner et al. [36]
      Peterson et al. [37]
Alternative (clinically equivalent to fluoroquinolone but not equivalent to bacteriological effect)
  Cefpodoxime proxetil 200 mg bid 10 Cronberg et al. [38]
  Ceftibuten 400 mg bid 10 Peterson et al. [37]
If an antibiotic susceptibility test is performed (not appropriate for primary treatment)
  Trimethoprim-sulphamethoxazole 160/800 mg bid 14   Rubin et al. [42]
  Co-amoxiclavb),c) 0.5/0.125 g tid 14  

Bid: twice a day, qd: once a day, tid: three times a day, Co-amoxiclav: amoxicillin-clavulanic acid.

Lower dose studied, but higher dose recommended by experts,

not studied as monotherapy in acute uncomplicated pyelonephritis,

mainly for Gram-positive pathogens.

Antibiotic susceptibility (%)

  AP SAM AK GM TOB CIP LFX SPT
Antibiotic sensitivity of Escherichia coli and Klebsiella pneumoniae
  E. coli 27.2 77.1 92.1 75.5 83.7 79.0 67.4 44.7
  K. pneumoniae 43.2 63.5 98.1 97.2 97.3 88.3 66.7 85.6
Antibiotic sensitivity of Gram(-) organisms between 2000 and 2004
  2000 year 38.5 79.3 91.7 83.1 85.3 80.2 67.5 59.0
  2004 year 18.9 74.4 95.4 72.1 79.1 76.7 65.5 38.1

Adapted from the article of Lee et al. J Korean Med Sci 2009;24:296-301 [19]. Comparison between E. coli and K. pneumoniae (p＜0.05). Comparison between 2000 and 2004 yr (p＜0.05).

AP: ampicillin, SAM: ampicillin/sulbactam, AK: amikacin, GM: gentamycin, TOB: tobramycin, CIP: ciprofloxacin, LFX: levofloxacin, SPT: trimetoprim/sulfamethoxazole.

Initial empirical antimicrobial therapy in acute uncomplicated pyelonephritis in premenopausal women (parenteral therapy: severe acute uncomplicated pyelonephritis)

Antibiotic Daily dose Reference
Ciprofloxacin 400 mg bid Talan et al. [35]
Levofloxacina) 250-500 mg qd Richard et al. [41]
Levofloxacin 750 mg qd Klausner et al. [36]
Alternative    
  Cefotaximeb) 2 g tid  
  Ceftriaxonea),d) 1-2 g qd Wells et al. [43]
  Ceftazidimeb) 1-2 g tid Mouton and Beuscart [44]
  Cefepimea),d) 1-2 g bid Giamarellou [45]
  Co-amoxiclavb),c) 1.5 g tid  
  Piperacillin/ 2.5-4.5 g tid Naber et al. [46]
  tazobactama),d)    
  Gentamicinb) 5 mg/kg qd  
  Amikacinb) 15 mg/kg qd  
  Ertapenemd) 1 g qd Wells et al. [43]
  Imipenem/cilastatind) 0.5/0.5 g tid Naber et al. [46]
  Meropenemd) 1 g tid Mouton and Beuscart [44]
  Doripenemd) 0.5 g tid Naber et al. [47]

Bid: twice a day, qd: once a day, tid: three times a day, Co-amoxiclav: amoxicillin-clavulanic acid.

Lower dose studied, but higher dose recommended by experts,

not studied as monotherapy in acute uncomplicated pyelonephritis,

mainly for Gram-positive pathogens,

same protocol for acute uncomplicated pyelonephritis and complicated urinary tract infection.