Page 16 - Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline

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American Urological Association (AUA)/Canadian Urological Association (CUA)/ Recurrent Uncomplicated
Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) Urinary Tract Infection

7. Clinicians should omit surveillance urine women, and 2) patients undergoing elective urologic
testing, including urine culture, in surgery. 90,112
asymptomatic patients with rUTIs. (Moderate ASB and Struvite Stones
Recommendation; Evidence Level: Grade C)
Certain bacteria (most commonly P. mirabilis) produce
Without symptoms, bacteriuria of any magnitude is urease and are associated with the development of
considered “ASB.” While pregnant women and patients infection (struvite) stones in the urinary tract. When
scheduled to undergo invasive urinary tract procedures infection stones are present, complete removal of the
do benefit from treatment, substantial evidence stones is required in order to eradicate the associated
supports that other populations, including women with UTI. However, there is no clear evidence that
diabetes mellitus and long-term care facility residents, identification and treatment of ASB caused by urease-
do not require or benefit from additional evaluation or producing organisms prevents struvite stone formation.
antimicrobial treatment.
Furthermore, this practice exposes patients to the
In women with rUTIs, there is no evidence that inherent risks associated with recurrent antibiotic
identification of ASB between UTI episodes provides therapy. For these reasons, the Panel does not
useful prognostic information. Prospective observational recommend the routine treatment of urease-producing
studies have found no differences in rates of bacteriuria (including P. mirabilis) in the absence of UTI
hypertension, chronic kidney disease, renal dysfunction, symptoms or documented urinary tract stones.
abnormal renal imaging, or mortality in women with or However, in certain patients with recurrent struvite
90
without bacteriuria. Additionally, evidence exists to stones, screening for and treating urease-producing
suggest a lack of effectiveness of treatment for ASB, bacteriuria may be indicated if other measures have not
which serves as indirect evidence that identification of been able to prevent stone formation. This is an area
ASB by surveillance testing would not result in where more research is required.
improved clinical outcomes, unless an alternative Antibiotic Treatment
40
effective treatment exists.
9. Clinicians should use first-line therapy (i.e.,
8. Clinicians should not treat ASB in patients. nitrofurantoin, TMP-SMX, fosfomycin)
(Strong Recommendation; Evidence Level: dependent on the local antibiogram for the
Grade B)
treatment of symptomatic UTIs in women.
Evaluation and treatment of rUTIs should be performed (Strong Recommendation; Evidence Level:
only when acute cystitis symptoms are present. In Grade B)
women with rUTIs, there is no evidence that treatment There is limited but older data from a Cochrane review
of ASB results in improved clinical outcomes, and there of studies published from 1977 to 2003 that compares
is clear evidence that these practices can cause harm antibiotics for uncomplicated UTIs. This systematic
(e.g., antibiotic side effects, development of review included 21 RCTs (N=6,016) of one antibiotic
opportunistic infections [e.g., C. difficile], antibiotic versus another for treatment of uncomplicated UTI. 113
resistance). One randomized trial of women (n=673, The systematic review found no differences between
median 40 years of age) with a history of rUTIs and fluoroquinolones, β-lactams (e.g., penicillins and its
ASB found that antibiotic treatment (versus no derivatives, cephalosporins), or nitrofurantoin versus
antibiotics) was associated with an increased risk of TMP-SMX in the likelihood of short-term (within two
symptomatic recurrence (47% versus 13%, RR 3.17, weeks of treatment) or long-term (up to 8 weeks)
95% 2.55 to 3.90) and development of antibiotic- symptomatic or bacteriological cure; relative risk
40
resistant organisms. These findings suggest that ASB estimates were close to 1.0 for all comparisons and
may actually prevent the development of symptomatic outcomes. Results were similar when trials of
UTIs. In addition, a recent systematic review concluded fluoroquinolones or β-lactams were stratified according
that antimicrobial treatment of ASB does not appear to to whether the duration of treatment was 3 days or 7 to
improve microbiologic outcomes, morbidity, or 10 days, or when trials of fluoroquinolones were
mortality. 110 Current evidence also indicates that stratified according to the specific medication
screening/treatment of ASB does not reduce UTI rates, (ciprofloxacin, ofloxacin, or norfloxacin).
morbidity, or mortality in “high-risk” patients (elderly, Fluoroquinolones (2 trials, pooled RR 0.08, 95% CI
immunosuppressed, renal transplant patients, 0.01 to 0.43; I =0%) and nitrofurantoin (3 trials,
2
diabetics). 90,111 The only clearly recognized indications pooled RR 0.17, 95% CI 0.04 to 0.76; I =0%) were
2
for screening/treatment of ASB are 1) pregnant

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