The Clinical Guidelines for Acute Uncomplicated Cystitis and Acute Uncomplicated Pyelonephritis

Ki Ho Kim; Jae Heon Kim; Seung-Ju Lee; Hong Chung; Jae Min Chung; Jae Hung Jung; Hyun Sop Choe; Hun Choi; Sun-Ju Lee

doi:10.14777/uti.2017.12.02.55

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Kim, Kim, Lee, Chung, Chung, Jung, Choe, Choi, Lee, and The Committee of The Korean Association of Urogenital Track Infection and Inflammation: The Clinical Guidelines for Acute Uncomplicated Cystitis and Acute Uncomplicated Pyelonephritis

Review

Urogenit Tract Infect 2017;12(2):55-64.

Published online: 19 August 2017

DOI: https://doi.org/10.14777/uti.2017.12.02.55

The Clinical Guidelines for Acute Uncomplicated Cystitis and Acute Uncomplicated Pyelonephritis

Ki Ho Kim, Jae Heon Kim¹, Seung-Ju Lee², Hong Chung³, Jae Min Chung⁴, Jae Hung Jung⁵, Hyun Sop Choe², Hun Choi⁶, Sun-Ju Lee⁷; The Committee of The Korean Association of Urogenital Track Infection and Inflammation

Department of Urology, Dongguk University College of Medicine, Gyeongju

¹Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul

²Department of Urology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon

³Department of Urology, Konkuk University Chungju Hospital, Konkuk University School of Medicine, Chungju

⁴Department of Urology, Pusan National University Yangsan Hospital, Yangsan

⁵Department of Urology, Yonsei University Wonju College of Medicine, Wonju

⁶Department of Urology, Korea University Ansan Hospital, Ansan

⁷Department 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

Received 10 April 2017 Revised 25 April 2017 Accepted 25 April 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.

Abstract

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.

Keywords: Cystitis, Pyelonephritis, Urinary tract infections, Guideline

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Fig. 1.

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

Fig. 2.

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

Table 1.

Empirical antibiotic therapy for acute uncomplicated cystitis

Antibiotic	Daily dose (oral)	Duration of therapy (d)
Fosfomycin trometamol	3 g qd	1
Pivmecillinam^a)	400 mg tid	3
Nitrofurantoin macrocrystal^a)	100 mg bid	5-7
-Lactams
Amoxicillin-clavulanic acid	250/125 mg tid	7
Amoxicillin-clavulanic acid	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
Ciprofloxacin^b)	500 mg bid	3
	500 mg SR qd
Tosufloxacin^b)	150 mg bid	3

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

^a) April 2016, not available in Korea,

^b) not available for pregnant women.

Table 2.

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

Table 3.

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.

Table 4.

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
Ciprofloxacin^a)	500-750 mg bid	7-10	Talan et al. [35]
Levofloxacin^a)	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-amoxiclav^b),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.

^a) Lower dose studied, but higher dose recommended by experts,

^b) not studied as monotherapy in acute uncomplicated pyelonephritis,

^c) mainly for Gram-positive pathogens.

Table 5.

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.

Table 6.

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]
Levofloxacin^a)	250-500 mg qd	Richard et al. [41]
Levofloxacin	750 mg qd	Klausner et al. [36]
Alternative
Cefotaxime^b)	2 g tid
Ceftriaxone^a),^d)	1-2 g qd	Wells et al. [43]
Ceftazidime^b)	1-2 g tid	Mouton and Beuscart [44]
Cefepime^a),^d)	1-2 g bid	Giamarellou [45]
Co-amoxiclav^b),^c)	1.5 g tid
Piperacillin/	2.5-4.5 g tid	Naber et al. [46]
tazobactam^a),^d)
Gentamicin^b)	5 mg/kg qd
Amikacin^b)	15 mg/kg qd
Ertapenem^d)	1 g qd	Wells et al. [43]
Imipenem/cilastatin^d)	0.5/0.5 g tid	Naber et al. [46]
Meropenem^d)	1 g tid	Mouton and Beuscart [44]
Doripenem^d)	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.

^a) Lower dose studied, but higher dose recommended by experts,

^b) not studied as monotherapy in acute uncomplicated pyelonephritis,

^c) mainly for Gram-positive pathogens,

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

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