Executive summary of the diagnosis and treatment of urinary tract infection: Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC) | Enfermedades Infecciosas y Microbiología Clínica

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"entidad" => "Servicio de Microbiología, Hospital Universitario de Álava, Vitoria-Gasteiz, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Enfermedades Infecciosas, Hospital Universitario Vall d’Hebron, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Enfermedades Infecciosas, Hospital Clínic-IDIBAPS, Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Enfermedades Infecciosas, Hospital Ramón y Cajal, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Área de Enfermedades Infecciosas, Clinica Universidad de Navarra, Pamplona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resumen ejecutivo del diagnóstico y tratamiento de las infecciones del tracto urinario. Guía de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC)" ] ] "textoCompleto" => "IntroductionUrinary tract infection (UTI) is one of the most common clinical problems in both the community and healthcare-associated settings. Community-acquired uncomplicated UTIs (uUTI) are particularly common among women, the vast majority of whom experience at least one episode of infection in their lifetime. A significant subset (25–40%) of women also develop recurrent urinary tract infections (rUTI), with multiple infections that recur over months, or years, in some cases. Other relevant clinical problems associated with UTI include asymptomatic bacteriuria (AB) and patients with complicated urinary tract infection (cUTI). Nosocomial UTI (generally a reflection of catheter-associated infections) constitutes about 20–30% of all hospital-acquired infections and are common sources of nosocomial bacteremia. One of the most important factors impacting the management of UTI in recent years has been the emergence of antimicrobial resistance among uropathogens, particularly isolates causing community-acquired UTI. Although at the moment antimicrobials can generally ensure the successful treatment or prevention of UTI, the emergence of antimicrobial resistance among uropathogens may soon limit our ability to do so.All the above reasons illustrate how variable and complex these infections are, which is why the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC) requested a panel of experts to provide an update on many of the issues involved, including the aetiology, microbiology, prevention, diagnosis, and treatment of various UTI syndromes. The related topic of prostatitis falls outside the scope of these guidelines. The present statement was written following SEIMC guidelines for consensus statements (<a id="intr0005" class="elsevierStyleInterRef" href="http://www.seimc.org/">www.seimc.org</a>), as well as Agree Collaboration (<a id="intr0010" class="elsevierStyleInterRef" href="http://www.agreecollaboration.org/">www.agreecollaboration.org</a>) recommendations for evaluating the methodological quality of clinical practice guidelines. Over various meetings, the authors selected a set of questions designed to form the basis of the document. Their recommendations are based on a systematic critical review of the literature including, when necessary, the opinion of experts, who are SEIMC members. Their recommendations have been adjusted according to the scientific evidence available (<a class="elsevierStyleCrossRef" href="#sec0285">Appendix A</a>). All the authors and the coordinators of the statement have agreed on the contents and conclusions of the document. Before final publication, the manuscript was made available online for all SEIMC members to read and to make comments and suggestions.Clinical impact of resistanceWhat microbiological and clinical data should be used to guide empiric treatment of UTI?Recommendations:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Studies of the susceptibility of uropathogens in the community tend to overestimate resistance rates. To guide empiric treatment, susceptibility and clinical data (type of UTI (uncomplicated versus complicated), sex, age and previous antibiotic therapy should be considered (A-II)).</li><li class="elsevierStyleListItem" id="lsti0010">•An antimicrobial agent is not recommended for empiric treatment of urinary tract infections if local resistance prevalence is over 20% for cystitis (B-II) or 10% for pyelonephritis (C-III).</li></ul>DiagnosisWhen is a urine culture necessary for the diagnosis of uncomplicated cystitis?Recommendations:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">•In women with uncomplicated cystitis, empiric treatment should be initiated on the basis of symptoms alone. A urine culture is generally not necessary (E-I).</li><li class="elsevierStyleListItem" id="lsti0020">•A pre-treatment urine culture should be obtained when the diagnosis is not clear from the history and physical examination, when the episode represents an early symptomatic recurrence, when there is reason to suspect antimicrobial resistance or the patient's therapeutic options are limited due to medication intolerance (A-II).</li><li class="elsevierStyleListItem" id="lsti0025">•Routine post-treatment cultures are not indicated for asymptomatic women following treatment for cystitis (E-II) and should only be obtained if symptoms persist or recur soon after treatment (A-II).</li></ul>Are blood cultures useful in the management of patients with acute pyelonephritis?Recommendations:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030">•The available evidence suggests that there is no need to routinely take a blood culture from women with uncomplicated pyelonephritis (E-II). It seems reasonable, however, to obtain a blood culture from patients with complicated infections, those receiving antibiotics or who have severe sepsis (B-II).</li></ul>What number of bacteria in urine is considered significant for the diagnosis of UTI?Recommendations:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0035">•Urine samples for culture should be collected in a manner that minimizes contamination (A-II).</li><li class="elsevierStyleListItem" id="lsti0040">•For symptomatic women, a culture definition for cystitis is ≥102CFU/mL (A-I) of a uropathogen, and for pyelonephritis ≥104CFU/mL (A-II). In non-catheter-related cystitis, counts of ≥102CFU/mL are significant in urine samples obtained by catheterization (B-III).</li><li class="elsevierStyleListItem" id="lsti0045">•In males with cystitis, a culture of ≥103CFU/mL is considered to be significant (A-III).</li><li class="elsevierStyleListItem" id="lsti0050">•In women with cystitis, the concomitant isolation of enterococci or group B streptococci with an enterobacteriaceae in a midstream urine culture has low clinical significance (A-I).</li><li class="elsevierStyleListItem" id="lsti0055">•In patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization, symptomatic UTI is microbiologically defined as the presence of ≥103CFU/mL of a bacterial species in a single catheter urine specimen or a midstream voided urine specimen from a patient whose urethral, suprapubic, or condom catheter has been removed within the previous 48h (A-III).</li><li class="elsevierStyleListItem" id="lsti0060">•In bladder urine obtained by suprapubic aspiration, any number of bacteria is considered to be significant (A-II).</li><li class="elsevierStyleListItem" id="lsti0065">•In women with asymptomatic bacteriuria, two consecutive clean-voided specimens with the same uropathogen at counts of ≥105CFU/mL, or one positive urine culture with a positive nitrite test in another sample, are required for diagnosis (B-II). In men, bacteriuria is defined as a single uropathogen isolated at a count of ≥105CFU/mL (B-III).</li><li class="elsevierStyleListItem" id="lsti0070">•Asymptomatic bacteriuria in patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization is microbiologically defined as the presence of ≥105CFU/mL of a bacterial species in a single catheter urine specimen or a midstream voided urine specimen from a patient whose urethral (A-III), suprapubic (A-III), or condom catheter (A-II) has been removed within the previous 48h.</li></ul>General aspects of antimicrobial therapy for the treatment of uncomplicated UTIsWhich pharmacokinetic/pharmacodynamics parameters of an antibiotic describe exposure-response relationships in general?Recommendations:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075">•Bacterial killing is best described by indices incorporating the antimicrobial's PK and PD parameters and the minimum inhibitory concentration (MIC), the lowest concentration of the antimicrobial required to prevent the growth of the target organism (B-II).</li></ul>Are urine-specific breakpoints necessary?Recommendations:<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0080">•Specific susceptibility breakpoints for UTI isolates are recommended (B-III). EUCAST and CLSI have published several breakpoints that are valid only for isolates in uncomplicated urinary tract infections.</li></ul>Is the antibiotic concentration in serum or urine the most important?Recommendations:<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0085">•Human data indicates that urinary concentrations are more closely associated with clinical outcomes than serum concentrations for lower UTI. For the treatment of pyelonephritis, however, high serum concentrations of the antimicrobial agent are required (A-III).</li><li class="elsevierStyleListItem" id="lsti0090">•With beta-lactams, the efficacy of sequential therapy may decrease due to the significant reduction in exposure to the active drug when switching to oral formulations for pathogens with higher MIC values (C-III).</li></ul>Asymptomatic bacteriuriaIs pyuria useful for diagnosing asymptomatic bacteriuria?. Are urine rapid tests recommended for screening of asymptomatic bacteriuria?Recommendations:<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0095">•Pyuria cannot be considered as an adequate criterion for the diagnosis of AB nor for indication for treatment in a patient with AB (A-II). Urine test stripes are not recommended for the detection of AB (A-II).</li></ul>Asymptomatic bacteriuria in at-risk populationsPregnant womenRecommendations:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0100">•Systematic screening and treatment of AB is recommended for pregnant women (A-I) in order to reduce the risk of pyelonephritis (A-I), preterm labour and low birth weight infants (B-II). An initial urine culture between the 12th and 16th weeks of pregnancy is recommended (A-I).</li><li class="elsevierStyleListItem" id="lsti0105">•A follow-up urine culture is recommended in order to verify that the bacteriuria has been eradicated (A-III). Subsequent monthly urine cultures until delivery are recommended (C-III).</li></ul>Patients who must undergo urological proceduresRecommendations:<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0110">•Systematic screening for and treatment of AB is recommended prior to performing a TURP of the prostate (A-I) or any other high-risk urological procedure (A-II).</li><li class="elsevierStyleListItem" id="lsti0115">•Screening and prophylaxis for AB is not recommended for patients scheduled to undergo low-risk urological procedures (A-I).</li><li class="elsevierStyleListItem" id="lsti0120">•Antibiotic prophylaxis should be initiated immediately before performing the procedure (A-II) and may be prolonged only in patients with a short-term urethral catheter, until removal (C-III).</li></ul>Premenopausal, non-pregnant womenRecommendations:<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0125">•Systematic screening for AB is not recommended for non-pregnant women under the age of 60 (E-I).</li><li class="elsevierStyleListItem" id="lsti0130">•Treatment of AB in non-pregnant women under the age of 60 increases the risk of sUTI and rates of antibiotic resistance (B-I).</li></ul>Diabetic womenRecommendation:<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0135">•Systematic screening for and treatment of AB is not recommended for non-pregnant diabetic women (E-I).</li></ul>Patients with urinary cathetersRecommendations:<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0140">•Systematic screening for and treatment of AB is not recommended for patients with short-term (E-II) or long-term urinary catheters (E-I).</li><li class="elsevierStyleListItem" id="lsti0145">•Treatment of AB in women is recommended only if AB persists 48h after removal of the catheter (B-I).</li><li class="elsevierStyleListItem" id="lsti0150">•Systemic antibiotic prophylaxis is not recommended during catheter replacement, since the risk of onset of symptomatic bacteremia is low (E-II); nonetheless, it may be recommended in cases of traumatic replacement associated with hematuria (C-III).</li></ul>Elderly persons residing in the communityRecommendation:<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0155">•Systematic screening and/or treatment of AB is not recommended for elderly patients living in the community (E-II).</li></ul>Elderly institutionalised subjectsRecommendation:<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0160">•Systematic screening and/or treatment of AB is not recommended for institutionalised elderly patients (E-I).</li></ul>Patients about to undergo orthopaedic surgeryRecommendations:<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0165">•Systematic diagnosis or treatment of AB is not recommended for patients scheduled to undergo total hip or knee arthroplasty (A-I).</li><li class="elsevierStyleListItem" id="lsti0170">•Screening and treatment of AB prior to performing instrumental spinal surgery is recommended for patients with urinary catheters, neurogenic bladders or urinary incontinence in order to reduce the risk of Gram-negative surgical site infections (B-II).</li></ul>Patients with spinal cord injuryRecommendation:<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0175">•Systematic screening and treatment of AB is not recommended for patients with spinal cord injury treated with intermittent urinary catheterization (E-II).</li></ul>Transplant recipientsRecommendations:<ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0180">•For kidney transplant patients, the screening and treatment of AB is only recommended in the first month after transplantation (B-III).</li><li class="elsevierStyleListItem" id="lsti0185">•For cases of hematopoietic stem cell transplants and SOTs other than kidney transplants, no recommendations for the screening and treatment of AB can be made (C-III).</li><li class="elsevierStyleListItem" id="lsti0190">•Systemic antifungal therapy for asymptomatic candiduria is not recommended for transplant patients, except for neutropenic patients or those scheduled to undergo urological procedures (D-III).</li></ul>Orthotopic neobladderRecommendation:<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0195">•Systematic screening and treatment of AB is not recommended in patients with an orthotopic neobladder (D-III).</li></ul>How long does it take to treat an asymptomatic bacteriuria?For pregnant women with asymptomatic bacteriuriaRecommendation:<ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0200">•Standard 4- to 7-day treatment regimens are better than short one-day treatments for eradicating bacteriuria (A-I). Only a single 3g dose of FT offers similar results to the standard treatment regimen (A-I).</li></ul>For patients scheduled to undergo high-risk urological proceduresRecommendations:<ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0205">•The administration of a single-dose of an appropriate antibiotic is recommended immediately prior to the procedure (A-II).</li><li class="elsevierStyleListItem" id="lsti0210">•Prolonging antibiotic treatment after these procedures is only recommended for patients with a short-term urethral catheter and until it has been removed (C-III).</li></ul>Treatment for acute uncomplicated cystitisWhat is the first-choice empiric antibiotic treatment recommended for acute uncomplicated cystitis?Recommendations:<ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0215">•Due to minimal resistance and propensity for collateral damage, fosfomycin-trometamol (3g in a single dose) and nitrofurantoin (for 5–7 days) are considered the first-choice drugs for therapy of uncomplicated cystitis (A-I).</li><li class="elsevierStyleListItem" id="lsti0220">•Fluoroquinolones (ciprofloxacin, levofloxacin and norfloxacin) are highly efficacious in 3-day regimens (A-I), but should be considered as alternative antimicrobials because of their high propensity for collateral damage (B-III).</li><li class="elsevierStyleListItem" id="lsti0225">•β-Lactam agents, including amoxicillin-clavulanate, cefuroxime, ceftibuten, for 5 days, and cefixime for 3 day regimens, are appropriate choices for therapy when other recommended agents cannot be used (B-I). β-Lactams generally have inferior efficacy and more adverse effects when compared with other UTI antimicrobials (B-I). Ampicillin and amoxicillin should not be used for the empiric treatment of uncomplicated cystitis, given the high incidence of antimicrobial resistance to these agents (E-I).</li><li class="elsevierStyleListItem" id="lsti0230">•Co-trimoxazole is not recommended for empiric treatment in Spain, because the resistance rate in E. coli is greater than 20% (E-I). If the infectious organism is susceptible to co-trimoxazole, this agent is very effective therapy (A-I).</li><li class="elsevierStyleListItem" id="lsti0235">•In men, and in women with symptoms longer than 7 days, recent UTI, diabetes, renal insufficiency, immunosuppression or with a vaginal diaphragm a longer course of antibiotic therapy (at least 7 days) is recommended (C-III).</li></ul>Community-acquired acute pyelonephritisWhat are the criteria for hospital admission in adult patients?Recommendations:<ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0240">•Women with uncomplicated APN and mild to moderate symptoms (fever <39°C, no severe flank pain, no vomiting) can be treated as outpatients (A-II).</li><li class="elsevierStyleListItem" id="lsti0245">•Women with uncomplicated APN but with social, mental or physical disabilities that might hinder adherence to a prescribed therapeutic regimen should be admitted to hospital (C-III).</li><li class="elsevierStyleListItem" id="lsti0250">•Women with uncomplicated APN and severe symptoms (fever ≥39°C, severe flank pain, vomiting) should be referred to an emergency room for evaluation, parenteral antibiotics and supportive measures (A-II). If, after 24h, there is improvement and good oral tolerance, the patient may be sent home with oral antibiotics (A-II).</li><li class="elsevierStyleListItem" id="lsti0255">•Patients with complicated APN or healthcare-associated APN and those with risk factors for MDR Enterobacteriaceae should be admitted to hospital (A-II).</li><li class="elsevierStyleListItem" id="lsti0260">•Pregnant women with otherwise uncomplicated APN and non-severe symptoms may be considered for treatment as outpatients if appropriate follow-up is assured (B-I). A normal abdominal ultrasonography is recommended before discharge (C-III).</li><li class="elsevierStyleListItem" id="lsti0265">•Selected APN patients with no severe sepsis, no obstructive uropathy (as recorded by ultrasonography), no altered mental status, no metabolic abnormalities and who have a responsible caregiver at home, may be managed in a hospital-based home care unit (B-III).</li></ul>What are the main therapeutic options for pyelonephritis in the different clinical situations, and which are not recommended for empiric treatment because of the high rate of resistance in our setting?Recommendations:<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0270">•In our setting, ampicillin, amoxicillin, amoxicillin-clavulanic acid, co-trimoxazole, fluoroquinolones, nitrofurantoin and fosfomycin-tromethamine are not recommended for the empiric treatment of acute pyelonephritis (A-III).</li><li class="elsevierStyleListItem" id="lsti0275">•Parenteral antibiotic treatment is recommended as initial therapy for patients requiring hospital admission (A-III).</li><li class="elsevierStyleListItem" id="lsti0280">•In patients with uncomplicated community-acquired acute pyelonephritis with no specific risk factors for ESBL-producing Enterobacteriaceae, empiric therapy with cefuroxime or a third-generation cephalosporin is recommended (A-II). For allergic patients, the alternatives are an aminoglycoside (B-I), aztreonam (B-II) or fosfomycin (C-III); a carbapenem is an acceptable option if the patient is closely monitored (C-III).</li><li class="elsevierStyleListItem" id="lsti0285">•In community-acquired APN with specific risk factors for ESBL-producing Enterobacteriaceae (at least two risk factors without severe sepsis and one with it) or previous infection/colonization with ESBL, ertapenem is an acceptable option (C-II), although other carbapenems (B-II) or piperacillin-tazobactam (B-III) are alternatives. For patients with penicillin allergy, the alternatives are amikacin (B-I) or intravenous sodium fosfomycin (C-III); a carbapenem is an acceptable option if the patient is closely monitored (C-III).</li><li class="elsevierStyleListItem" id="lsti0290">•In healthcare-associated APN, an antipseudomonal carbapenem is recommended (A-III) with ceftolozane-tazobactam or piperacillin-tazobactam as alternatives (C-III). For patients with severe sepsis, the addition of amikacin should be considered in order to increase the chances of providing appropriate empiric therapy against Gram-negative bacilli (B-II). For patients allergic to penicillin, alternative treatments are aztreonam, amikacin or intravenous sodium fosfomycin±amikacin (C-III); a carbapenem is an acceptable option if the patient is closely monitored (C-III).</li><li class="elsevierStyleListItem" id="lsti0295">•Anti-enterococcal coverage is recommended for patients with healthcare-related APN and severe sepsis or cardiac conditions at high risk of endocarditis (C-III).</li><li class="elsevierStyleListItem" id="lsti0300">•When the antibiotic susceptibility pattern is known, treatment should preferably be adjusted to the drug with least ecological impact, such as co-trimoxazole (C-III).</li></ul>What is the optimal duration of antibiotic therapy? Does it vary depending on the particular antibiotic administered?Recommendations:<ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0305">•In patients with uncomplicated acute pyelonephritis due to susceptible Gram-negative enteric bacilli, 5–7 days of levofloxacin or ciprofloxacin is recommended (A-I).</li><li class="elsevierStyleListItem" id="lsti0310">•In the case of third-generation oral or parenteral cephalosporins, a 7 to 10-day course is recommended (A-I). For amoxicillin-clavulanic acid and co-trimoxazole a 10-day course is recommended (A-III). For aminoglycosides, no more than a 5-day course is recommended (A-II).</li><li class="elsevierStyleListItem" id="lsti0315">•For patients with severe or focal APN or slow response to appropriate antibiotics, a longer duration of therapy may be required (C-III).</li></ul>What are the main indications for performing urological studies?Recommendations:<ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0320">•Urological studies are only recommended for patients with uncomplicated APN who continue with fever after 3 days of appropriate antibiotic treatment (A-III), for APN that fulfils the definition of complicated infection in these guidelines (including severe sepsis) (A-III) or for recurrent APN (C-III).</li><li class="elsevierStyleListItem" id="lsti0325">•Urological study should also be considered when the clinical diagnosis is doubtful, either to confirm it or to rule out other processes (C-III).</li></ul>Catheter-associated urinary tract infectionWhat is the etiology of UTI in patients with urinary catheters?Recommendations:<ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0330">•In patients with short-term catheterization, UTI is usually monomicrobial and frequently caused by Enterobacteriaceae (B-II).</li><li class="elsevierStyleListItem" id="lsti0335">•In patients with long-term catheterization, UTI is usually polymicrobial and frequently caused by antimicrobial-resistant bacteria (B-II).</li></ul>What are the clinical and microbiologial features for diagnosis of symptomatic CA-UTI?Recommendations:<ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0340">•If an indwelling catheter has been in place for >2 weeks, the catheter should be replaced before obtaining urine for culture (A-II).</li><li class="elsevierStyleListItem" id="lsti0345">•Signs and symptoms compatible with CA-UTI include fever, rigors, altered mental state or malaise with no other identifiable cause, as well as focal signs in the urinary tract, such as flank or pelvic pain, costovertebral angle tenderness, and acute hematuria (A-III).</li><li class="elsevierStyleListItem" id="lsti0350">•In catheterised patients, the presence of urinary symptoms is of limited value for differentiating CA-AB from CA-UTI (A-I). In patients whose catheters have been removed, the presence of urinary symptoms is suggestive of symptomatic UTI (A-III).</li><li class="elsevierStyleListItem" id="lsti0355">•In patients with spinal cord injuries, increased spasticity, autonomic dysreflexia, or a sense of unease are suggestive of CA-UTI (A-III).</li><li class="elsevierStyleListItem" id="lsti0360">•In patients with indwelling catheters residing in LTCFs, the clinical criteria for obtaining urine cultures and initiating antimicrobial therapy include fever, costovertebral angle tenderness, rigors or new onset delirium with no other obvious source (A-II).</li><li class="elsevierStyleListItem" id="lsti0365">•In catheterised patients, the presence or absence of odorous or cloudy urine should not be used to distinguish CA-AB from CA-UTI or as an indication for a urine culture or antimicrobial therapy (A-III).</li></ul>Does the presence of pyuria indicate symptomatic UTI?Recommendations:<ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0370">•In catheterised patients, pyuria is not diagnostic of CA-AB or CA-UTI (A-II). The absence of pyuria in a symptomatic patient suggests a diagnosis other than CA-UTI (A-III).</li></ul>Is the Gram stain useful for guiding empiric antimicrobial treatment in CA-UTI?Recommendation:<ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0375">•In catheterised patients, the urine Gram stain may be useful for guiding empiric antibiotic therapy in patients with severe UTI (B-III).</li></ul>Should previous antibiotic use be considered for the selection of empiric therapy of CA-UTI?Recommendation:<ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0380">•In catheterised patients with suspected UTI, recent use of beta-lactams or quinolones should be investigated in order to evaluate the risk for MDR bacteria (B-II).</li></ul>What is the empiric antimicrobial therapy for patients with CA-UTI?Recommendations:<ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0385">•Antimicrobial therapy is indicated for patients with symptomatic infection or clinical signs of sepsis (B-III).</li><li class="elsevierStyleListItem" id="lsti0390">•Patients with symptomatic UTI and criteria for severe sepsis should be treated with parenteral broad-spectrum antibiotics adapted to the local resistance patterns of uropathogens (C-III). Imipenem, meropenem and piperacillin/tazobactam are the most active antimicrobials in our setting. If the patient has septic shock or resistance to beta-lactams is suspected, combination therapy with amikacin should be considered (C-III).</li><li class="elsevierStyleListItem" id="lsti0395">•If the patient presents with symptoms of mild infection and a urinary origin is unlikely, antimicrobial therapy can be delayed until the urine culture results are known (C-III).</li></ul>How long should antimicrobial therapy for CA-UTI lastRecommendations:<ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0400">•Seven days is the usual duration of antimicrobial therapy for CA-UTI patients with prompt resolution of symptoms, and patients with cystitis following urinary catheterization (A-III); 10–14 days of treatment is recommended for those with delayed response (A-III), regardless of whether the patient remains catheterised or not.</li><li class="elsevierStyleListItem" id="lsti0405">•A 5-day course of levofloxacin may be considered for patients with mild CA-UTI (B-III). A 3-day course of antimicrobials (B-II) or a single-dose of fosfomycin trometamol (3g) (C-III) may be considered for women who develop CA-UTI without upper urinary tract symptoms after removal of an indwelling catheter.</li><li class="elsevierStyleListItem" id="lsti0410">•Antibiotic prophylaxis should not be administered to patients for catheter placement (E-I) catheter removal (D-I) or replacement (E-III) in order to prevent CA-UTI.</li></ul>What are the most important measures for prevention of CA-AB and CA-UTI?Recommendations:<ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0415">•Indwelling catheters should be placed only when they indicated (A-III) and should be removed as soon as they are no longer required, in order to reduce the risk of CA-AB (A-I) and CA-UTI (A-II). Indwelling catheters should be inserted using the aseptic technique and sterile equipment (B-III) and a closed catheter drainage system should be maintained to reduce CA-AB and CA-UTI (A-II and A-III, respectively, for patients with short-term catheters; A-III and A-III, respectively, for patients with long-term catheters).</li><li class="elsevierStyleListItem" id="lsti0420">•Appropriate alternatives to short- and long-term urethral catheterization should be considered for reducing CA-AB, such as condom catheterization (A-II and B-II, respectively) intermittent catheterization (C-I and A-III, respectively), and suprapubic catheterization (B-I for short-term catheterization). Alternatives for reducing CA-UTI are intermittent catheterization (C-III for short-term and A-III for long-term catheterization) and suprapubic catheterization (C-III for short-term catheterization).</li><li class="elsevierStyleListItem" id="lsti0425">•In patients with short-term indwelling urethral catheterization, antimicrobial (antibiotic or silver alloy)-coated urinary catheters may reduce or delay the onset of CA-AB, but does not decrease the frequency of CA-UTI (B-II).</li><li class="elsevierStyleListItem" id="lsti0430">•Systemic antibiotic prophylaxis should not be routinely used to reduce CA-AB or CA-UTI in patients with short-term (A-III) or long-term (A-II) catheterization because of the concern of selection of antimicrobial resistance.</li></ul>Risk factors and prevention strategies for recurrent urinary tract infections (rUTI)What are the main risk factors of rUTI in premenopausal women?Recommendations:<ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0435">•In sexually active women, the main risk factor for rUTI is frequency of sexual intercourse (B-I).</li><li class="elsevierStyleListItem" id="lsti0440">•In sexually active women with rUTI, it is not necessary to perform a urological study if there is no suspicion of underlying urological disease (A-II).</li></ul>Are hygienic measures effective in preventing rUTI?Recommendation:<ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0445">•In women who fail to prevent rUTI with hygiene measures, it is not necessary to insist on their implementation (B-II).</li></ul>Is acidification of the urine useful for preventing rUTI?Recommendations:<ul class="elsevierStyleList" id="lis0185"><li class="elsevierStyleListItem" id="lsti0450">•Vitamin C (ascorbic acid) in acceptable dosing intervals in regular clinical practice is not useful in the prevention of rUTI (B-II).</li><li class="elsevierStyleListItem" id="lsti0455">•Although methenamine hippurate is useful for preventing rUTI (B-I), we do not recommend its use, given the potential carcinogenic risks (C-III).</li></ul>When is it advisable to use prevention strategies?Recommendations:<ul class="elsevierStyleList" id="lis0190"><li class="elsevierStyleListItem" id="lsti0460">•In women with fewer than 3 UTIs per year, self-treatment of cystitis is a convenient and effective measure and also reduces the consumption of antibiotics associated with prophylaxis (B-II).</li><li class="elsevierStyleListItem" id="lsti0465">•The administration of continuous (A-I) or post-coital (A-I) antibiotics, topical vaginal estrogens (A-I), cranberries (A-II) or D-Mannose (A-II) for a 6-month period reduces the frequency of rUTI to a greater or lesser extent.</li></ul>What is the efficacy of continuous or postcoital antibiotic prophylaxis?Recommendations:<ul class="elsevierStyleList" id="lis0195"><li class="elsevierStyleListItem" id="lsti0470">•In women with rUTI, continuous or postcoital antibiotic prophylaxis administered for 6–12 months is highly effective for reducing recurrence (A-I).</li><li class="elsevierStyleListItem" id="lsti0475">•The effectiveness of the different antibiotics used in prophylaxis (COT, NIT, trimethoprim, FQs and cephalosporins) is similar (B-II).</li><li class="elsevierStyleListItem" id="lsti0480">•If UTI recurs after cessation of prophylaxis, it is recommended to restart the same prophylaxis regimen for a longer period (1–2 years) (C-III).</li><li class="elsevierStyleListItem" id="lsti0485">•Due to its ecological impact, prophylaxis with FQs should be used only when no other preventive strategy is available (C-III).</li></ul>What is the role of cranberries in preventing rUTI? Is antibiotic prophylaxis more effective than cranberries in the prevention of rUTI?Recommendations:<ul class="elsevierStyleList" id="lis0200"><li class="elsevierStyleListItem" id="lsti0490">•Cranberries administered for 6–12 months are moderately effective in preventing new episodes of UTI in patients with rUTI (A-I); in patients with few UTIs, they are not effective (A-II).</li><li class="elsevierStyleListItem" id="lsti0495">•Antibiotic prophylaxis is more effective than cranberries (A-I).</li><li class="elsevierStyleListItem" id="lsti0500">•A 72mg dose, or higher, of PAC is recommended (C-III).</li></ul>What are the main predisposing factors in postmenopausal women?Recommendations:<ul class="elsevierStyleList" id="lis0205"><li class="elsevierStyleListItem" id="lsti0505">•In menopausal women without neurological diseases, the main risk factors for suffering rUTI are urinary incontinence, previous gynaecological surgery, presence of diabetes mellitus, a cystocele, residual urine and a history of rUTI before menopause (B-II).</li><li class="elsevierStyleListItem" id="lsti0510">•The role of sexual activity is less relevant as a predisposing factor for recurrence in postmenopausal women (B-II).</li></ul>What is the effectiveness of topical vaginal estrogens preventing rUTI?Recommendations:<ul class="elsevierStyleList" id="lis0210"><li class="elsevierStyleListItem" id="lsti0515">•Oral administration of estrogen does not reduce rUTI (E-I).</li><li class="elsevierStyleListItem" id="lsti0520">•Vaginal estrogen significantly reduces rUTI (A-II).</li><li class="elsevierStyleListItem" id="lsti0525">•It is not known whether antibiotic prophylaxis is more efficacious than vaginal creams (C-II).</li><li class="elsevierStyleListItem" id="lsti0530">•Vaginal estrogen administration is the prophylaxis of choice when associated with vaginal atrophy and should always be considered in all postmenopausal patients (C-III).</li></ul>Are vaccines useful in the prevention of rUTI?Recommendations:<ul class="elsevierStyleList" id="lis0215"><li class="elsevierStyleListItem" id="lsti0535">•Oral and intranasal vaccines (OM-89) made from uropathogenic bacterial extracts are moderately effective in preventing rUTI (B-II).</li><li class="elsevierStyleListItem" id="lsti0540">•There are no adequate studies assessing the effectiveness of other commercialised preparations (C-III).</li></ul>Other prevention strategiesRecommendations:<ul class="elsevierStyleList" id="lis0220"><li class="elsevierStyleListItem" id="lsti0545">•There is insufficient evidence to recommend vaginal application of lactobacilli as a strategy for preventing rUTI (B-II).</li><li class="elsevierStyleListItem" id="lsti0550">•D-mannose is effective in preventing rUTI (A-II). Its effectiveness is similar to nitrofurantoin for this indication (A-II).</li></ul>Conflict of interestThe authors declare no conflicts of interest." 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Executive summary of the diagnosis and treatment of urinary tract infection: Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC)

Resumen ejecutivo del diagnóstico y tratamiento de las infecciones del tracto urinario. Guía de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC)

Marina de Cuetoa, Luis Aliagab, Juan-Ignacio Alósc, Andres Canutd, Ibai Los-Arcose, Jose Antonio Martínezf, Jose Mensaf, Vicente Pintadog, Dolors Rodriguez-Pardoe, Jose Ramon Yusteh, Carles Pigraue,

Corresponding author

cpigrau@vhebron.net

Corresponding author.

a Unidad Clinica Intercentros de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocio, Sevilla, Spain

b Unidad de Gestión Clínica de Medicina Interna, Hospital Universitario Unificado de Granada, Granada, Spain

c Servicio de Microbiología, Hospital Universitario de Getafe, Getafe, Spain

d Servicio de Microbiología, Hospital Universitario de Álava, Vitoria-Gasteiz, Spain

e Servicio de Enfermedades Infecciosas, Hospital Universitario Vall d’Hebron, Barcelona, Spain

f Servicio de Enfermedades Infecciosas, Hospital Clínic-IDIBAPS, Barcelona, Spain

g Servicio de Enfermedades Infecciosas, Hospital Ramón y Cajal, Madrid, Spain

h Área de Enfermedades Infecciosas, Clinica Universidad de Navarra, Pamplona, Spain

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        "titulo" => "Resumen ejecutivo del diagn&#243;stico y tratamiento de las infecciones del tracto urinario&#46; Gu&#237;a de la Sociedad Espa&#241;ola de Enfermedades Infecciosas y Microbiolog&#237;a Cl&#237;nica &#40;SEIMC&#41;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Urinary tract infection &#40;UTI&#41; is one of the most common clinical problems in both the community and healthcare-associated settings&#46; Community-acquired uncomplicated UTIs &#40;uUTI&#41; are particularly common among women&#44; the vast majority of whom experience at least one episode of infection in their lifetime&#46; A significant subset &#40;25&#8211;40&#37;&#41; of women also develop recurrent urinary tract infections &#40;rUTI&#41;&#44; with multiple infections that recur over months&#44; or years&#44; in some cases&#46; Other relevant clinical problems associated with UTI include asymptomatic bacteriuria &#40;AB&#41; and patients with complicated urinary tract infection &#40;cUTI&#41;&#46; Nosocomial UTI &#40;generally a reflection of catheter-associated infections&#41; constitutes about 20&#8211;30&#37; of all hospital-acquired infections and are common sources of nosocomial bacteremia&#46; One of the most important factors impacting the management of UTI in recent years has been the emergence of antimicrobial resistance among uropathogens&#44; particularly isolates causing community-acquired UTI&#46; Although at the moment antimicrobials can generally ensure the successful treatment or prevention of UTI&#44; the emergence of antimicrobial resistance among uropathogens may soon limit our ability to do so&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">All the above reasons illustrate how variable and complex these infections are&#44; which is why the Spanish Society of Clinical Microbiology and Infectious Diseases &#40;SEIMC&#41; requested a panel of experts to provide an update on many of the issues involved&#44; including the aetiology&#44; microbiology&#44; prevention&#44; diagnosis&#44; and treatment of various UTI syndromes&#46; The related topic of prostatitis falls outside the scope of these guidelines&#46; The present statement was written following SEIMC guidelines for consensus statements &#40;<a id="intr0005" class="elsevierStyleInterRef" href="http://www.seimc.org/">www&#46;seimc&#46;org</a>&#41;&#44; as well as <span class="elsevierStyleItalic">Agree Collaboration</span> &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://www.agreecollaboration.org/">www&#46;agreecollaboration&#46;org</a>&#41; recommendations for evaluating the methodological quality of clinical practice guidelines&#46; Over various meetings&#44; the authors selected a set of questions designed to form the basis of the document&#46; Their recommendations are based on a systematic critical review of the literature including&#44; when necessary&#44; the opinion of experts&#44; who are SEIMC members&#46; Their recommendations have been adjusted according to the scientific evidence available &#40;<a class="elsevierStyleCrossRef" href="#sec0285">Appendix A</a>&#41;&#46; All the authors and the coordinators of the statement have agreed on the contents and conclusions of the document&#46; Before final publication&#44; the manuscript was made available online for all SEIMC members to read and to make comments and suggestions&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical impact of resistance</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">What microbiological and clinical data should be used to guide empiric treatment of UTI&#63;</span><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Studies of the susceptibility of uropathogens in the community tend to overestimate resistance rates&#46; To guide empiric treatment&#44; susceptibility and clinical data &#40;type of UTI &#40;uncomplicated versus complicated&#41;&#44; sex&#44; age and previous antibiotic therapy should be considered &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">An antimicrobial agent is not recommended for empiric treatment of urinary tract infections if local resistance prevalence is over 20&#37; for cystitis &#40;<span class="elsevierStyleBold">B-II</span>&#41; or 10&#37; for pyelonephritis &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Diagnosis</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">When is a urine culture necessary for the diagnosis of uncomplicated cystitis&#63;</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">In women with uncomplicated cystitis&#44; empiric treatment should be initiated on the basis of symptoms alone&#46; A urine culture is generally not necessary &#40;<span class="elsevierStyleBold">E-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">A pre-treatment urine culture should be obtained when the diagnosis is not clear from the history and physical examination&#44; when the episode represents an early symptomatic recurrence&#44; when there is reason to suspect antimicrobial resistance or the patient&#39;s therapeutic options are limited due to medication intolerance &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Routine post-treatment cultures are not indicated for asymptomatic women following treatment for cystitis &#40;<span class="elsevierStyleBold">E-II</span>&#41; and should only be obtained if symptoms persist or recur soon after treatment &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Are blood cultures useful in the management of patients with acute pyelonephritis&#63;</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">The available evidence suggests that there is no need to routinely take a blood culture from women with uncomplicated pyelonephritis &#40;<span class="elsevierStyleBold">E-II</span>&#41;&#46; It seems reasonable&#44; however&#44; to obtain a blood culture from patients with complicated infections&#44; those receiving antibiotics or who have severe sepsis &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">What number of bacteria in urine is considered significant for the diagnosis of UTI&#63;</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Urine samples for culture should be collected in a manner that minimizes contamination &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">For symptomatic women&#44; a culture definition for cystitis is &#8805;10<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;mL &#40;<span class="elsevierStyleBold">A-I</span>&#41; of a uropathogen&#44; and for pyelonephritis &#8805;10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;mL &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46; In non-catheter-related cystitis&#44; counts of &#8805;10<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;mL are significant in urine samples obtained by catheterization &#40;<span class="elsevierStyleBold">B-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">In males with cystitis&#44; a culture of &#8805;10<span class="elsevierStyleSup">3</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;mL is considered to be significant &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">In women with cystitis&#44; the concomitant isolation of enterococci or group B streptococci with an enterobacteriaceae in a midstream urine culture has low clinical significance &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">In patients with indwelling urethral&#44; indwelling suprapubic&#44; or intermittent catheterization&#44; symptomatic UTI is microbiologically defined as the presence of &#8805;10<span class="elsevierStyleSup">3</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;mL of a bacterial species in a single catheter urine specimen or a midstream voided urine specimen from a patient whose urethral&#44; suprapubic&#44; or condom catheter has been removed within the previous 48<span class="elsevierStyleHsp" style=""></span>h &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">In bladder urine obtained by suprapubic aspiration&#44; any number of bacteria is considered to be significant &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">In women with asymptomatic bacteriuria&#44; two consecutive clean-voided specimens with the same uropathogen at counts of &#8805;10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;mL&#44; or one positive urine culture with a positive nitrite test in another sample&#44; are required for diagnosis &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46; In men&#44; bacteriuria is defined as a single uropathogen isolated at a count of &#8805;10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;mL &#40;<span class="elsevierStyleBold">B-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Asymptomatic bacteriuria in patients with indwelling urethral&#44; indwelling suprapubic&#44; or intermittent catheterization is microbiologically defined as the presence of &#8805;10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;mL of a bacterial species in a single catheter urine specimen or a midstream voided urine specimen from a patient whose urethral &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#44; suprapubic &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#44; or condom catheter &#40;<span class="elsevierStyleBold">A-II</span>&#41; has been removed within the previous 48<span class="elsevierStyleHsp" style=""></span>h&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">General aspects of antimicrobial therapy for the treatment of uncomplicated UTIs</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Which pharmacokinetic&#47;pharmacodynamics parameters of an antibiotic describe exposure-response relationships in general&#63;</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Bacterial killing is best described by indices incorporating the antimicrobial&#39;s PK and PD parameters and the minimum inhibitory concentration &#40;MIC&#41;&#44; the lowest concentration of the antimicrobial required to prevent the growth of the target organism &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Are urine-specific breakpoints necessary&#63;</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Specific susceptibility breakpoints for UTI isolates are recommended &#40;<span class="elsevierStyleBold">B-III</span>&#41;&#46; EUCAST and CLSI have published several breakpoints that are valid only for isolates in uncomplicated urinary tract infections&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Is the antibiotic concentration in serum or urine the most important&#63;</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Human data indicates that urinary concentrations are more closely associated with clinical outcomes than serum concentrations for lower UTI&#46; For the treatment of pyelonephritis&#44; however&#44; high serum concentrations of the antimicrobial agent are required &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">With beta-lactams&#44; the efficacy of sequential therapy may decrease due to the significant reduction in exposure to the active drug when switching to oral formulations for pathogens with higher MIC values &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Asymptomatic bacteriuria</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Is pyuria useful for diagnosing asymptomatic bacteriuria&#63;&#46; Are urine rapid tests recommended for screening of asymptomatic bacteriuria&#63;</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Pyuria cannot be considered as an adequate criterion for the diagnosis of AB nor for indication for treatment in a patient with AB &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46; Urine test stripes are not recommended for the detection of AB &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Asymptomatic bacteriuria in at-risk populations</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Pregnant women</span><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Systematic screening and treatment of AB is recommended for pregnant women &#40;<span class="elsevierStyleBold">A-I</span>&#41; in order to reduce the risk of pyelonephritis &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#44; preterm labour and low birth weight infants &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46; An initial urine culture between the 12th and 16th weeks of pregnancy is recommended &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">A follow-up urine culture is recommended in order to verify that the bacteriuria has been eradicated &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46; Subsequent monthly urine cultures until delivery are recommended &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patients who must undergo urological procedures</span><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Systematic screening for and treatment of AB is recommended prior to performing a TURP of the prostate &#40;<span class="elsevierStyleBold">A-I</span>&#41; or any other high-risk urological procedure &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Screening and prophylaxis for AB is not recommended for patients scheduled to undergo low-risk urological procedures &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Antibiotic prophylaxis should be initiated immediately before performing the procedure &#40;<span class="elsevierStyleBold">A-II</span>&#41; and may be prolonged only in patients with a short-term urethral catheter&#44; until removal &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Premenopausal&#44; non-pregnant women</span><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Systematic screening for AB is not recommended for non-pregnant women under the age of 60 &#40;<span class="elsevierStyleBold">E-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Treatment of AB in non-pregnant women under the age of 60 increases the risk of sUTI and rates of antibiotic resistance &#40;<span class="elsevierStyleBold">B-I</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Diabetic women</span><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendation&#58;</span><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Systematic screening for and treatment of AB is not recommended for non-pregnant diabetic women &#40;<span class="elsevierStyleBold">E-I</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Patients with urinary catheters</span><p id="par0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Systematic screening for and treatment of AB is not recommended for patients with short-term &#40;<span class="elsevierStyleBold">E-II</span>&#41; or long-term urinary catheters &#40;<span class="elsevierStyleBold">E-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Treatment of AB in women is recommended only if AB persists 48<span class="elsevierStyleHsp" style=""></span>h after removal of the catheter &#40;<span class="elsevierStyleBold">B-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Systemic antibiotic prophylaxis is not recommended during catheter replacement&#44; since the risk of onset of symptomatic bacteremia is low &#40;<span class="elsevierStyleBold">E-II</span>&#41;&#59; nonetheless&#44; it may be recommended in cases of traumatic replacement associated with hematuria &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Elderly persons residing in the community</span><p id="par0230" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendation&#58;</span><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Systematic screening and&#47;or treatment of AB is not recommended for elderly patients living in the community &#40;<span class="elsevierStyleBold">E-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Elderly institutionalised subjects</span><p id="par0240" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendation&#58;</span><ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Systematic screening and&#47;or treatment of AB is not recommended for institutionalised elderly patients &#40;<span class="elsevierStyleBold">E-I</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Patients about to undergo orthopaedic surgery</span><p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Systematic diagnosis or treatment of AB is not recommended for patients scheduled to undergo total hip or knee arthroplasty &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Screening and treatment of AB prior to performing instrumental spinal surgery is recommended for patients with urinary catheters&#44; neurogenic bladders or urinary incontinence in order to reduce the risk of Gram-negative surgical site infections &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Patients with spinal cord injury</span><p id="par0265" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendation&#58;</span><ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8226;</span><p id="par0270" class="elsevierStylePara elsevierViewall">Systematic screening and treatment of AB is not recommended for patients with spinal cord injury treated with intermittent urinary catheterization &#40;<span class="elsevierStyleBold">E-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Transplant recipients</span><p id="par0275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8226;</span><p id="par0280" class="elsevierStylePara elsevierViewall">For kidney transplant patients&#44; the screening and treatment of AB is only recommended in the first month after transplantation &#40;<span class="elsevierStyleBold">B-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8226;</span><p id="par0285" class="elsevierStylePara elsevierViewall">For cases of hematopoietic stem cell transplants and SOTs other than kidney transplants&#44; no recommendations for the screening and treatment of AB can be made &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8226;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Systemic antifungal therapy for asymptomatic candiduria is not recommended for transplant patients&#44; except for neutropenic patients or those scheduled to undergo urological procedures &#40;<span class="elsevierStyleBold">D-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Orthotopic neobladder</span><p id="par0295" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendation&#58;</span><ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8226;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Systematic screening and treatment of AB is not recommended in patients with an orthotopic neobladder &#40;<span class="elsevierStyleBold">D-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">How long does it take to treat an asymptomatic bacteriuria&#63;</span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">For pregnant women with asymptomatic bacteriuria</span><p id="par0305" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendation&#58;</span><ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8226;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Standard 4- to 7-day treatment regimens are better than short one-day treatments for eradicating bacteriuria &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46; Only a single 3<span class="elsevierStyleHsp" style=""></span>g dose of FT offers similar results to the standard treatment regimen &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">For patients scheduled to undergo high-risk urological procedures</span><p id="par0315" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0320" class="elsevierStylePara elsevierViewall">The administration of a single-dose of an appropriate antibiotic is recommended immediately prior to the procedure &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8226;</span><p id="par0325" class="elsevierStylePara elsevierViewall">Prolonging antibiotic treatment after these procedures is only recommended for patients with a short-term urethral catheter and until it has been removed &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span></span></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Treatment for acute uncomplicated cystitis</span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">What is the first-choice empiric antibiotic treatment recommended for acute uncomplicated cystitis&#63;</span><p id="par0330" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8226;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Due to minimal resistance and propensity for collateral damage&#44; fosfomycin-trometamol &#40;3<span class="elsevierStyleHsp" style=""></span>g in a single dose&#41; and nitrofurantoin &#40;for 5&#8211;7 days&#41; are considered the first-choice drugs for therapy of uncomplicated cystitis &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">&#8226;</span><p id="par0340" class="elsevierStylePara elsevierViewall">Fluoroquinolones &#40;ciprofloxacin&#44; levofloxacin and norfloxacin&#41; are highly efficacious in 3-day regimens &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#44; but should be considered as alternative antimicrobials because of their high propensity for collateral damage &#40;<span class="elsevierStyleBold">B-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">&#8226;</span><p id="par0345" class="elsevierStylePara elsevierViewall">&#946;-Lactam agents&#44; including amoxicillin-clavulanate&#44; cefuroxime&#44; ceftibuten&#44; for 5 days&#44; and cefixime for 3 day regimens&#44; are appropriate choices for therapy when other recommended agents cannot be used &#40;<span class="elsevierStyleBold">B-I</span>&#41;&#46; &#946;-Lactams generally have inferior efficacy and more adverse effects when compared with other UTI antimicrobials &#40;<span class="elsevierStyleBold">B-I</span>&#41;&#46; Ampicillin and amoxicillin should not be used for the empiric treatment of uncomplicated cystitis&#44; given the high incidence of antimicrobial resistance to these agents &#40;<span class="elsevierStyleBold">E-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8226;</span><p id="par0350" class="elsevierStylePara elsevierViewall">Co-trimoxazole is not recommended for empiric treatment in Spain&#44; because the resistance rate in <span class="elsevierStyleItalic">E&#46; coli</span> is greater than 20&#37; &#40;<span class="elsevierStyleBold">E-I</span>&#41;&#46; If the infectious organism is susceptible to co-trimoxazole&#44; this agent is very effective therapy &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8226;</span><p id="par0355" class="elsevierStylePara elsevierViewall">In men&#44; and in women with symptoms longer than 7 days&#44; recent UTI&#44; diabetes&#44; renal insufficiency&#44; immunosuppression or with a vaginal diaphragm a longer course of antibiotic therapy &#40;at least 7 days&#41; is recommended &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Community-acquired acute pyelonephritis</span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">What are the criteria for hospital admission in adult patients&#63;</span><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8226;</span><p id="par0365" class="elsevierStylePara elsevierViewall">Women with uncomplicated APN and mild to moderate symptoms &#40;fever &#60;39<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; no severe flank pain&#44; no vomiting&#41; can be treated as outpatients &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">&#8226;</span><p id="par0370" class="elsevierStylePara elsevierViewall">Women with uncomplicated APN but with social&#44; mental or physical disabilities that might hinder adherence to a prescribed therapeutic regimen should be admitted to hospital &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">&#8226;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Women with uncomplicated APN and severe symptoms &#40;fever &#8805;39<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; severe flank pain&#44; vomiting&#41; should be referred to an emergency room for evaluation&#44; parenteral antibiotics and supportive measures &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46; If&#44; after 24<span class="elsevierStyleHsp" style=""></span>h&#44; there is improvement and good oral tolerance&#44; the patient may be sent home with oral antibiotics &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">&#8226;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Patients with complicated APN or healthcare-associated APN and those with risk factors for MDR Enterobacteriaceae should be admitted to hospital &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">&#8226;</span><p id="par0385" class="elsevierStylePara elsevierViewall">Pregnant women with otherwise uncomplicated APN and non-severe symptoms may be considered for treatment as outpatients if appropriate follow-up is assured &#40;<span class="elsevierStyleBold">B-I</span>&#41;&#46; A normal abdominal ultrasonography is recommended before discharge &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">&#8226;</span><p id="par0390" class="elsevierStylePara elsevierViewall">Selected APN patients with no severe sepsis&#44; no obstructive uropathy &#40;as recorded by ultrasonography&#41;&#44; no altered mental status&#44; no metabolic abnormalities and who have a responsible caregiver at home&#44; may be managed in a hospital-based home care unit &#40;<span class="elsevierStyleBold">B-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">What are the main therapeutic options for pyelonephritis in the different clinical situations&#44; and which are not recommended for empiric treatment because of the high rate of resistance in our setting&#63;</span><p id="par0395" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">&#8226;</span><p id="par0400" class="elsevierStylePara elsevierViewall">In our setting&#44; ampicillin&#44; amoxicillin&#44; amoxicillin-clavulanic acid&#44; co-trimoxazole&#44; fluoroquinolones&#44; nitrofurantoin and fosfomycin-tromethamine are not recommended for the empiric treatment of acute pyelonephritis &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">&#8226;</span><p id="par0405" class="elsevierStylePara elsevierViewall">Parenteral antibiotic treatment is recommended as initial therapy for patients requiring hospital admission &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">&#8226;</span><p id="par0410" class="elsevierStylePara elsevierViewall">In patients with uncomplicated community-acquired acute pyelonephritis with no specific risk factors for ESBL-producing Enterobacteriaceae&#44; empiric therapy with cefuroxime or a third-generation cephalosporin is recommended &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46; For allergic patients&#44; the alternatives are an aminoglycoside &#40;<span class="elsevierStyleBold">B-I</span>&#41;&#44; aztreonam &#40;<span class="elsevierStyleBold">B-II</span>&#41; or fosfomycin &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#59; a carbapenem is an acceptable option if the patient is closely monitored &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">&#8226;</span><p id="par0415" class="elsevierStylePara elsevierViewall">In community-acquired APN with specific risk factors for ESBL-producing Enterobacteriaceae &#40;at least two risk factors without severe sepsis and one with it&#41; or previous infection&#47;colonization with ESBL&#44; ertapenem is an acceptable option &#40;<span class="elsevierStyleBold">C-II</span>&#41;&#44; although other carbapenems &#40;<span class="elsevierStyleBold">B-II</span>&#41; or piperacillin-tazobactam &#40;<span class="elsevierStyleBold">B-III</span>&#41; are alternatives&#46; For patients with penicillin allergy&#44; the alternatives are amikacin &#40;<span class="elsevierStyleBold">B-I</span>&#41; or intravenous sodium fosfomycin &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#59; a carbapenem is an acceptable option if the patient is closely monitored &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">&#8226;</span><p id="par0420" class="elsevierStylePara elsevierViewall">In healthcare-associated APN&#44; an antipseudomonal carbapenem is recommended &#40;<span class="elsevierStyleBold">A-III</span>&#41; with ceftolozane-tazobactam or piperacillin-tazobactam as alternatives &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46; For patients with severe sepsis&#44; the addition of amikacin should be considered in order to increase the chances of providing appropriate empiric therapy against Gram-negative bacilli &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46; For patients allergic to penicillin&#44; alternative treatments are aztreonam&#44; amikacin or intravenous sodium fosfomycin<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>amikacin &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#59; a carbapenem is an acceptable option if the patient is closely monitored &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">&#8226;</span><p id="par0425" class="elsevierStylePara elsevierViewall">Anti-enterococcal coverage is recommended for patients with healthcare-related APN and severe sepsis or cardiac conditions at high risk of endocarditis &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">&#8226;</span><p id="par0430" class="elsevierStylePara elsevierViewall">When the antibiotic susceptibility pattern is known&#44; treatment should preferably be adjusted to the drug with least ecological impact&#44; such as co-trimoxazole &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">What is the optimal duration of antibiotic therapy&#63; Does it vary depending on the particular antibiotic administered&#63;</span><p id="par0435" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">&#8226;</span><p id="par0440" class="elsevierStylePara elsevierViewall">In patients with uncomplicated acute pyelonephritis due to susceptible Gram-negative enteric bacilli&#44; 5&#8211;7 days of levofloxacin or ciprofloxacin is recommended &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">&#8226;</span><p id="par0445" class="elsevierStylePara elsevierViewall">In the case of third-generation oral or parenteral cephalosporins&#44; a 7 to 10-day course is recommended &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46; For amoxicillin-clavulanic acid and co-trimoxazole a 10-day course is recommended &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46; For aminoglycosides&#44; no more than a 5-day course is recommended &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">&#8226;</span><p id="par0450" class="elsevierStylePara elsevierViewall">For patients with severe or focal APN or slow response to appropriate antibiotics&#44; a longer duration of therapy may be required &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">What are the main indications for performing urological studies&#63;</span><p id="par0455" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">&#8226;</span><p id="par0460" class="elsevierStylePara elsevierViewall">Urological studies are only recommended for patients with uncomplicated APN who continue with fever after 3 days of appropriate antibiotic treatment &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#44; for APN that fulfils the definition of complicated infection in these guidelines &#40;including severe sepsis&#41; &#40;<span class="elsevierStyleBold">A-III</span>&#41; or for recurrent APN &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">&#8226;</span><p id="par0465" class="elsevierStylePara elsevierViewall">Urological study should also be considered when the clinical diagnosis is doubtful&#44; either to confirm it or to rule out other processes &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Catheter-associated urinary tract infection</span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">What is the etiology of UTI in patients with urinary catheters&#63;</span><p id="par0470" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">&#8226;</span><p id="par0475" class="elsevierStylePara elsevierViewall">In patients with short-term catheterization&#44; UTI is usually monomicrobial and frequently caused by Enterobacteriaceae &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">&#8226;</span><p id="par0480" class="elsevierStylePara elsevierViewall">In patients with long-term catheterization&#44; UTI is usually polymicrobial and frequently caused by antimicrobial-resistant bacteria &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">What are the clinical and microbiologial features for diagnosis of symptomatic CA-UTI&#63;</span><p id="par0485" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">&#8226;</span><p id="par0490" class="elsevierStylePara elsevierViewall">If an indwelling catheter has been in place for &#62;2 weeks&#44; the catheter should be replaced before obtaining urine for culture &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">&#8226;</span><p id="par0495" class="elsevierStylePara elsevierViewall">Signs and symptoms compatible with CA-UTI include fever&#44; rigors&#44; altered mental state or malaise with no other identifiable cause&#44; as well as focal signs in the urinary tract&#44; such as flank or pelvic pain&#44; costovertebral angle tenderness&#44; and acute hematuria &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">&#8226;</span><p id="par0500" class="elsevierStylePara elsevierViewall">In catheterised patients&#44; the presence of urinary symptoms is of limited value for differentiating CA-AB from CA-UTI &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46; In patients whose catheters have been removed&#44; the presence of urinary symptoms is suggestive of symptomatic UTI &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">&#8226;</span><p id="par0505" class="elsevierStylePara elsevierViewall">In patients with spinal cord injuries&#44; increased spasticity&#44; autonomic dysreflexia&#44; or a sense of unease are suggestive of CA-UTI &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">&#8226;</span><p id="par0510" class="elsevierStylePara elsevierViewall">In patients with indwelling catheters residing in LTCFs&#44; the clinical criteria for obtaining urine cultures and initiating antimicrobial therapy include fever&#44; costovertebral angle tenderness&#44; rigors or new onset delirium with no other obvious source &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">&#8226;</span><p id="par0515" class="elsevierStylePara elsevierViewall">In catheterised patients&#44; the presence or absence of odorous or cloudy urine should not be used to distinguish CA-AB from CA-UTI or as an indication for a urine culture or antimicrobial therapy &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Does the presence of pyuria indicate symptomatic UTI&#63;</span><p id="par0520" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">&#8226;</span><p id="par0525" class="elsevierStylePara elsevierViewall">In catheterised patients&#44; pyuria is not diagnostic of CA-AB or CA-UTI &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46; The absence of pyuria in a symptomatic patient suggests a diagnosis other than CA-UTI &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Is the Gram stain useful for guiding empiric antimicrobial treatment in CA-UTI&#63;</span><p id="par0530" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendation&#58;</span><ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">&#8226;</span><p id="par0535" class="elsevierStylePara elsevierViewall">In catheterised patients&#44; the urine Gram stain may be useful for guiding empiric antibiotic therapy in patients with severe UTI &#40;<span class="elsevierStyleBold">B-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Should previous antibiotic use be considered for the selection of empiric therapy of CA-UTI&#63;</span><p id="par0540" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendation&#58;</span><ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">&#8226;</span><p id="par0545" class="elsevierStylePara elsevierViewall">In catheterised patients with suspected UTI&#44; recent use of beta-lactams or quinolones should be investigated in order to evaluate the risk for MDR bacteria &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">What is the empiric antimicrobial therapy for patients with CA-UTI&#63;</span><p id="par0550" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">&#8226;</span><p id="par0555" class="elsevierStylePara elsevierViewall">Antimicrobial therapy is indicated for patients with symptomatic infection or clinical signs of sepsis &#40;<span class="elsevierStyleBold">B-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">&#8226;</span><p id="par0560" class="elsevierStylePara elsevierViewall">Patients with symptomatic UTI and criteria for severe sepsis should be treated with parenteral broad-spectrum antibiotics adapted to the local resistance patterns of uropathogens &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46; Imipenem&#44; meropenem and piperacillin&#47;tazobactam are the most active antimicrobials in our setting&#46; If the patient has septic shock or resistance to beta-lactams is suspected&#44; combination therapy with amikacin should be considered &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">&#8226;</span><p id="par0565" class="elsevierStylePara elsevierViewall">If the patient presents with symptoms of mild infection and a urinary origin is unlikely&#44; antimicrobial therapy can be delayed until the urine culture results are known &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">How long should antimicrobial therapy for CA-UTI last</span><p id="par0570" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">&#8226;</span><p id="par0575" class="elsevierStylePara elsevierViewall">Seven days is the usual duration of antimicrobial therapy for CA-UTI patients with prompt resolution of symptoms&#44; and patients with cystitis following urinary catheterization &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#59; 10&#8211;14 days of treatment is recommended for those with delayed response &#40;<span class="elsevierStyleBold">A-III</span>&#41;&#44; regardless of whether the patient remains catheterised or not&#46;</p></li><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">&#8226;</span><p id="par0580" class="elsevierStylePara elsevierViewall">A 5-day course of levofloxacin may be considered for patients with mild CA-UTI &#40;<span class="elsevierStyleBold">B-III</span>&#41;&#46; A 3-day course of antimicrobials &#40;<span class="elsevierStyleBold">B-II</span>&#41; or a single-dose of fosfomycin trometamol &#40;3<span class="elsevierStyleHsp" style=""></span>g&#41; &#40;<span class="elsevierStyleBold">C-III</span>&#41; may be considered for women who develop CA-UTI without upper urinary tract symptoms after removal of an indwelling catheter&#46;</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">&#8226;</span><p id="par0585" class="elsevierStylePara elsevierViewall">Antibiotic prophylaxis should not be administered to patients for catheter placement &#40;<span class="elsevierStyleBold">E-I</span>&#41; catheter removal &#40;<span class="elsevierStyleBold">D-I</span>&#41; or replacement &#40;<span class="elsevierStyleBold">E-III</span>&#41; in order to prevent CA-UTI&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">What are the most important measures for prevention of CA-AB and CA-UTI&#63;</span><p id="par0590" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">&#8226;</span><p id="par0595" class="elsevierStylePara elsevierViewall">Indwelling catheters should be placed only when they indicated &#40;<span class="elsevierStyleBold">A-III</span>&#41; and should be removed as soon as they are no longer required&#44; in order to reduce the risk of CA-AB &#40;<span class="elsevierStyleBold">A-I</span>&#41; and CA-UTI &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46; Indwelling catheters should be inserted using the aseptic technique and sterile equipment &#40;<span class="elsevierStyleBold">B-III</span>&#41; and a closed catheter drainage system should be maintained to reduce CA-AB and CA-UTI &#40;<span class="elsevierStyleBold">A-II</span> and <span class="elsevierStyleBold">A-III</span>&#44; respectively&#44; for patients with short-term catheters&#59; <span class="elsevierStyleBold">A-III</span> and <span class="elsevierStyleBold">A-III</span>&#44; respectively&#44; for patients with long-term catheters&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">&#8226;</span><p id="par0600" class="elsevierStylePara elsevierViewall">Appropriate alternatives to short- and long-term urethral catheterization should be considered for reducing CA-AB&#44; such as condom catheterization &#40;<span class="elsevierStyleBold">A-II</span> and <span class="elsevierStyleBold">B-II</span>&#44; respectively&#41; intermittent catheterization &#40;<span class="elsevierStyleBold">C-I</span> and <span class="elsevierStyleBold">A-III</span>&#44; respectively&#41;&#44; and suprapubic catheterization &#40;<span class="elsevierStyleBold">B-I</span> for short-term catheterization&#41;&#46; Alternatives for reducing CA-UTI are intermittent catheterization &#40;<span class="elsevierStyleBold">C-III</span> for short-term and <span class="elsevierStyleBold">A-III</span> for long-term catheterization&#41; and suprapubic catheterization &#40;<span class="elsevierStyleBold">C-III</span> for short-term catheterization&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">&#8226;</span><p id="par0605" class="elsevierStylePara elsevierViewall">In patients with short-term indwelling urethral catheterization&#44; antimicrobial &#40;antibiotic or silver alloy&#41;-coated urinary catheters may reduce or delay the onset of CA-AB&#44; but does not decrease the frequency of CA-UTI &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">&#8226;</span><p id="par0610" class="elsevierStylePara elsevierViewall">Systemic antibiotic prophylaxis should not be routinely used to reduce CA-AB or CA-UTI in patients with short-term &#40;<span class="elsevierStyleBold">A-III</span>&#41; or long-term &#40;<span class="elsevierStyleBold">A-II</span>&#41; catheterization because of the concern of selection of antimicrobial resistance&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Risk factors and prevention strategies for recurrent urinary tract infections &#40;rUTI&#41;</span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">What are the main risk factors of rUTI in premenopausal women&#63;</span><p id="par0615" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">&#8226;</span><p id="par0620" class="elsevierStylePara elsevierViewall">In sexually active women&#44; the main risk factor for rUTI is frequency of sexual intercourse &#40;<span class="elsevierStyleBold">B-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">&#8226;</span><p id="par0625" class="elsevierStylePara elsevierViewall">In sexually active women with rUTI&#44; it is not necessary to perform a urological study if there is no suspicion of underlying urological disease &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">Are hygienic measures effective in preventing rUTI&#63;</span><p id="par0630" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendation&#58;</span><ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">&#8226;</span><p id="par0635" class="elsevierStylePara elsevierViewall">In women who fail to prevent rUTI with hygiene measures&#44; it is not necessary to insist on their implementation &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0260">Is acidification of the urine useful for preventing rUTI&#63;</span><p id="par0640" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0185"><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">&#8226;</span><p id="par0645" class="elsevierStylePara elsevierViewall">Vitamin C &#40;ascorbic acid&#41; in acceptable dosing intervals in regular clinical practice is not useful in the prevention of rUTI &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">&#8226;</span><p id="par0650" class="elsevierStylePara elsevierViewall">Although methenamine hippurate is useful for preventing rUTI &#40;<span class="elsevierStyleBold">B-I</span>&#41;&#44; we do not recommend its use&#44; given the potential carcinogenic risks &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0265">When is it advisable to use prevention strategies&#63;</span><p id="par0655" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0190"><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">&#8226;</span><p id="par0660" class="elsevierStylePara elsevierViewall">In women with fewer than 3 UTIs per year&#44; self-treatment of cystitis is a convenient and effective measure and also reduces the consumption of antibiotics associated with prophylaxis &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">&#8226;</span><p id="par0665" class="elsevierStylePara elsevierViewall">The administration of continuous &#40;<span class="elsevierStyleBold">A-I</span>&#41; or post-coital &#40;<span class="elsevierStyleBold">A-I</span>&#41; antibiotics&#44; topical vaginal estrogens &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#44; cranberries &#40;<span class="elsevierStyleBold">A-II</span>&#41; or D-Mannose &#40;<span class="elsevierStyleBold">A-II</span>&#41; for a 6-month period reduces the frequency of rUTI to a greater or lesser extent&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0270">What is the efficacy of continuous or postcoital antibiotic prophylaxis&#63;</span><p id="par0670" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0195"><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">&#8226;</span><p id="par0675" class="elsevierStylePara elsevierViewall">In women with rUTI&#44; continuous or postcoital antibiotic prophylaxis administered for 6&#8211;12 months is highly effective for reducing recurrence &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">&#8226;</span><p id="par0680" class="elsevierStylePara elsevierViewall">The effectiveness of the different antibiotics used in prophylaxis &#40;COT&#44; NIT&#44; trimethoprim&#44; FQs and cephalosporins&#41; is similar &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">&#8226;</span><p id="par0685" class="elsevierStylePara elsevierViewall">If UTI recurs after cessation of prophylaxis&#44; it is recommended to restart the same prophylaxis regimen for a longer period &#40;1&#8211;2 years&#41; &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel">&#8226;</span><p id="par0690" class="elsevierStylePara elsevierViewall">Due to its ecological impact&#44; prophylaxis with FQs should be used only when no other preventive strategy is available &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0275">What is the role of cranberries in preventing rUTI&#63; Is antibiotic prophylaxis more effective than cranberries in the prevention of rUTI&#63;</span><p id="par0695" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0200"><li class="elsevierStyleListItem" id="lsti0490"><span class="elsevierStyleLabel">&#8226;</span><p id="par0700" class="elsevierStylePara elsevierViewall">Cranberries administered for 6&#8211;12 months are moderately effective in preventing new episodes of UTI in patients with rUTI &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#59; in patients with few UTIs&#44; they are not effective &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0495"><span class="elsevierStyleLabel">&#8226;</span><p id="par0705" class="elsevierStylePara elsevierViewall">Antibiotic prophylaxis is more effective than cranberries &#40;<span class="elsevierStyleBold">A-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0500"><span class="elsevierStyleLabel">&#8226;</span><p id="par0710" class="elsevierStylePara elsevierViewall">A 72<span class="elsevierStyleHsp" style=""></span>mg dose&#44; or higher&#44; of PAC is recommended &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0280">What are the main predisposing factors in postmenopausal women&#63;</span><p id="par0715" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0205"><li class="elsevierStyleListItem" id="lsti0505"><span class="elsevierStyleLabel">&#8226;</span><p id="par0720" class="elsevierStylePara elsevierViewall">In menopausal women without neurological diseases&#44; the main risk factors for suffering rUTI are urinary incontinence&#44; previous gynaecological surgery&#44; presence of diabetes mellitus&#44; a cystocele&#44; residual urine and a history of rUTI before menopause &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0510"><span class="elsevierStyleLabel">&#8226;</span><p id="par0725" class="elsevierStylePara elsevierViewall">The role of sexual activity is less relevant as a predisposing factor for recurrence in postmenopausal women &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0270" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0285">What is the effectiveness of topical vaginal estrogens preventing rUTI&#63;</span><p id="par0730" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0210"><li class="elsevierStyleListItem" id="lsti0515"><span class="elsevierStyleLabel">&#8226;</span><p id="par0735" class="elsevierStylePara elsevierViewall">Oral administration of estrogen does not reduce rUTI &#40;<span class="elsevierStyleBold">E-I</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0520"><span class="elsevierStyleLabel">&#8226;</span><p id="par0740" class="elsevierStylePara elsevierViewall">Vaginal estrogen significantly reduces rUTI &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0525"><span class="elsevierStyleLabel">&#8226;</span><p id="par0745" class="elsevierStylePara elsevierViewall">It is not known whether antibiotic prophylaxis is more efficacious than vaginal creams &#40;<span class="elsevierStyleBold">C-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0530"><span class="elsevierStyleLabel">&#8226;</span><p id="par0750" class="elsevierStylePara elsevierViewall">Vaginal estrogen administration is the prophylaxis of choice when associated with vaginal atrophy and should always be considered in all postmenopausal patients &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0275" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0290">Are vaccines useful in the prevention of rUTI&#63;</span><p id="par0755" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0215"><li class="elsevierStyleListItem" id="lsti0535"><span class="elsevierStyleLabel">&#8226;</span><p id="par0760" class="elsevierStylePara elsevierViewall">Oral and intranasal vaccines &#40;OM-89&#41; made from uropathogenic bacterial extracts are moderately effective in preventing rUTI &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0540"><span class="elsevierStyleLabel">&#8226;</span><p id="par0765" class="elsevierStylePara elsevierViewall">There are no adequate studies assessing the effectiveness of other commercialised preparations &#40;<span class="elsevierStyleBold">C-III</span>&#41;&#46;</p></li></ul><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0280" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0295">Other prevention strategies</span><p id="par0770" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Recommendations&#58;</span><ul class="elsevierStyleList" id="lis0220"><li class="elsevierStyleListItem" id="lsti0545"><span class="elsevierStyleLabel">&#8226;</span><p id="par0775" class="elsevierStylePara elsevierViewall">There is insufficient evidence to recommend vaginal application of lactobacilli as a strategy for preventing rUTI &#40;<span class="elsevierStyleBold">B-II</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0550"><span class="elsevierStyleLabel">&#8226;</span><p id="par0780" class="elsevierStylePara elsevierViewall">D-mannose is effective in preventing rUTI &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46; Its effectiveness is similar to nitrofurantoin for this indication &#40;<span class="elsevierStyleBold">A-II</span>&#41;&#46;</p></li></ul></p></span></span><span id="sec0295" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0300">Conflict of interest</span><p id="par0795" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Most urinary tract infections &#40;UTI&#41; are uncomplicated infections occurring in young women&#46; An extensive evaluation is not required in the majority of cases&#44; and they can be safely managed as outpatients with oral antibiotics&#46; <span class="elsevierStyleItalic">Escherichia coli</span> is by far the most common uropathogen&#44; accounting for &#62;80&#37; of all cases&#46; Other major clinical problems associated with UTI include asymptomatic bacteriuria&#44; and patients with complicated UTI&#46; Complicated UTIs are a heterogeneous group associated with conditions that increase the risk of acquiring infection or treatment failure&#46; Distinguishing between complicated and uncomplicated UTI is important&#44; as it influences the initial evaluation&#44; choice&#44; and duration of antimicrobial therapy&#46; Diagnosis is especially challenging in the elderly and in patients with in-dwelling catheters&#46; The increasing prevalence of resistant uropathogens&#44; including extended-spectrum &#946;-lactamases and carbapenemase-producing Enterobacteriaceae&#44; and other multidrug-resistant Gram-negative organisms further compromises treatment of both complicated and uncomplicated UTIs&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The aim of these Clinical Guidelines is to provide a set of recommendations for improving the diagnosis and treatment of UTI&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de infecciones del tracto urinario &#40;ITU&#41; son infecciones no complicadas que se presentan en mujeres j&#243;venes&#46; En la mayor&#237;a de los casos no se requieren pruebas diagn&#243;sticas complementarias y se pueden tratar ambulatoriamente de forma segura con antibi&#243;ticos por v&#237;a oral&#46; <span class="elsevierStyleItalic">Escherichia coli</span> es el uropat&#243;geno m&#225;s frecuente causando m&#225;s del 80&#37; de estas infecciones&#46; La bacteriuria asintom&#225;tica &#40;BA&#41; y las ITUs complicadas son otras formas de presentaci&#243;n de la ITU&#46; Las ITU complicadas son un grupo heterog&#233;neo de condiciones que incrementan el riesgo de adquisici&#243;n de la infecci&#243;n o de fracaso del tratamiento&#46; La distinci&#243;n entre ITU complicada y no complicada es fundamental para decidir la evaluaci&#243;n inicial del paciente&#44; la elecci&#243;n del antimicrobiano y la duraci&#243;n del mismo&#46; El diagn&#243;stico es especialmente dif&#237;cil en ancianos y en pacientes con sondaje permanente&#46; El incremento de cepas resistentes a los antibi&#243;ticos&#44; especialmente Enterobacter&#237;as productoras de beta-lactamasas de espectro extendido y de carbapenemasas y de otros Gram negativos multirresistentes&#44; dificultan la elecci&#243;n del tratamiento de las ITU complicadas y no complicadas&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El objetivo de esta gu&#237;a cl&#237;nica es proporcionar recomendaciones basadas en la evidencia para mejorar el diagn&#243;stico y tratamiento de las ITU&#46;</p></span>"
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Article information

ISSN: 0213005X
Original language: English

DOI:10.1016/j.eimc.2016.11.005

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2018 December	146	84	230
2018 November	238	152	390
2018 October	220	111	331
2018 September	171	70	241
2018 August	63	15	78
2018 July	98	16	114
2018 June	158	22	180
2018 May	167	26	193
2018 April	223	23	246
2018 March	423	24	447
2018 February	380	24	404
2018 January	447	43	490
2017 December	315	37	352
2017 November	431	55	486
2017 October	71	18	89
2017 September	17	5	22
2017 August	32	1	33
2017 July	33	2	35
2017 June	37	16	53
2017 May	223	222	445
2017 April	6	6	12
2017 March	5	9	14
2017 February	538	103	641
2017 January	1940	116	2056
2016 December	0	19	19

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