Información del artículo
El tratamiento antibiótico empírico de las infecciones del tracto urinario inferior debe basarse en los datos clínicos del paciente y en las tasas locales de sensibilidad antibiótica. El aumento de las resistencias de los uropatógenos ha obligado a modificar las recomendaciones para el tratamiento empírico de las infecciones urinarias. Actualmente se desaconseja el uso empírico de cotrimoxazol, ampicilina, cefalosporinas y quinolonas, ambas de primera generación. Las fluoroquinolonas han demostrado ser muy eficaces en estudios comparativos, pero el aumento de resistencias obliga a seleccionar el tipo de paciente que se puede beneficiar de estos antimicrobianos. Las cefalosporinas de segunda y tercera generación mantienen tasas de sensibilidad elevadas, aunque se deben tener en cuenta las mayores tasas de recurrencia asociadas a su utilización y la aparición de enterobacterias productoras de betalactamasas de espectro extendido en la comunidad. La amoxicilina-ácido clavulánico tiene menor eficacia erradicadora que las quinolonas. Fosfomicina-trometamol mantiene tasas de resistencia inferiores al 2% y ha demostrado su eficacia y seguridad con una dosis única. Nitrofurantoína también es activa en la actualidad, aunque precisa una administración de 7 días y no está exenta de toxicidad. Ambos agentes se recomiendan actualmente como opciones alternativas a las fluoroquinolonas en la infección no complicada del tracto urinario inferior.
Palabras clave:
Infección del tracto urinario inferior
Tratamiento antibiótico empírico
Resistencias
Empirical antibiotic treatment of lower urinary tract infections should be based on the patient's clinical data and on local sensitivity data. Because of the increase in resistance among uropathogens, recommendations on the empirical treatment of urinary tract infections have been modified. Currently, the empirical use of co-trimoxazole, ampicillin, and first-generation cephalosporins and quinolones is not recommended. Fluoroquinolones have been demonstrated to be highly effective in comparative studies but, because of the increase in resistance, the type of patient who can benefit from these antimicrobial agents must be selected. Second- and third-generation cephalosporins still have high sensitivity rates, although the higher recurrence rates associated with their use and the emergence of extended-spectrum beta-lactamaseproducing enterobacterial in the community should be taken into account. Amoxicillin-clavulanate is less effective in eradicating infections than quinolones. Fosfomycintrometamol has resistance rates of below 2% and single-dose therapy has been demonstrated to be safe and effective. Nitrofurantoin is also currently active, although it must be administered for 7 days and can produce toxicity. Both agents are currently recommended as alternative therapeutic options to fluoroquinolones in uncomplicated infections of the lower urinary tract.
Key words:
Lower urinary tract infection
Empirical antibiotic therapy
Resistance
El Texto completo está disponible en PDF
Bibliografía
[1.]
T.M. Hooton, W.E. Stamm.
Diagnosis and treatment of uncomplicated urinary tract infection.
Infect Dis Clin North Am, 11 (1997), pp. 551-581
[2.]
B. Foxman, R. Barlow, H. D’Arcy, B. Gillespie, J.D. Sobel.
Urinary tract infection: self-reported incidence and associated costs.
Ann Epidemiol, 10 (2000), pp. 509-515
[3.]
E.J. Ernst, M.E. Ernst, J.D. Hoehns, G.R. Bergus.
Women's quality of life is decreased by acute cystitis and antibiotic adverse effects associated with treatment.
Health Qual Life Outcomes, 3 (2005), pp. 45
[4.]
S. Bent, B.K. Nallamothu, D. Simel, S.D. Fihn, S. Saint.
Does this woman have an acute uncomplicated urinary tract infection?.
JAMA, 287 (2002), pp. 2701-2710
[5.]
E.S. Wong, M. McKevitt, K. Running, G.W. Counts, M. Turck, W.E. Stamm.
Management of recurrent urinary tract infections with patient-administered single-dose therapy.
Ann Intern Med, 102 (1985), pp. 302-307
[6.]
K. Gupta, T.M. Hooton, P.L. Roberts, W.E. Stamm.
Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women.
Ann Intern Med, 135 (2001), pp. 9-16
[7.]
P.G. Pappas.
Laboratory in the diagnosis and management of urinary tract infections.
J Gen Intern Med, 75 (1991), pp. 313
[8.]
T.A. Hurlbut 3rd, B. Littenberg.
The diagnostic accuracy of rapid dipstick test to predict urinary tract infection.
Am J Clin Pathol, 96 (1991), pp. 582-588
[9.]
W.L. Deville, J.C. Yzermans, N.P. Van Duijn, P.D. Bezemer, D.A. Van der Windt, L.M. Bouter.
The urine dipstick test useful to rule out infections. A meta-analysis of the accuracy.
BMC Urol, 4 (2004), pp. 4
[10.]
W.E. Stamm, G.W. Counts, K.R. Running, S. Fihn, M. Turck, K.K. Holmes.
Diagnosis of coliform infection in acutely dysuric women.
N Engl J Med, 307 (1982), pp. 463-468
[11.]
H.C. Barry, M.H. Ebell, J. Hickner.
Evaluation of suspected urinary tract infection in ambulatory women: a cost-utility analysis of office-based strategies.
J Fam Pract, 44 (1997), pp. 49-60
[12.]
W.E. Stamm, T.M. Hooton.
Management of urinary tract infections in adults.
N Engl J Med, 329 (1993), pp. 1328-1334
[13.]
K. Gupta, D. Scholes, W.E. Stamm.
Increasing prevalence of antimicrobial resistance among uropathogens causing acute uncomplicated cystitis in women.
JAMA, 281 (1999), pp. 736-739
[14.]
G. Kahlmeter.
An international survey of the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections: the ECO-SENS project.
J Antimicrob Chemother, 51 (2003), pp. 69-76
[15.]
Pigrau C, Horcajada JP, Cartón JA, Pujol M, Mensa J. Infección urinaria. Protocolos Clínicos SEIMC 2002. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. Disponible en: http://www.seimc.org/protocolos/clinicos
[16.]
L. Nicolle.
Urinary tract infection: traditional pharmacologic therapies.
Am J Med, 113 (2002), pp. 35S-44S
[17.]
L.G. Miller, A.W. Tang.
Treatment of uncomplicated urinary tract infections in an era of increasing antimicrobial resistance.
Mayo Clin Proc, 79 (2004), pp. 1048-1053
[18.]
J.W. Warren, E. Abrutyn, J.R. Hebel, J.R. Johnson, A.J. Schaeffer, W.E. Stamm.
Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA).
Clin Infect Dis, 29 (1999), pp. 745-758
[19.]
A. Andreu, J.I. Alos, M. Gobernado, F. Marco, M. De la Rosa, J.A. García-Rodríguez.
Etiología y sensibilidad a los antimicrobianos de los uropatógenos causantes de la infección urinaria baja adquirida en la comunidad. Estudio nacional multicéntrico.
Enferm Infecc Microbiol Clin, 23 (2005), pp. 4-9
[20.]
S. Junquera, E. Loza, F. Baquero.
Evolución del patrón de sensibilidad de aislados de Escherichia coli en urocultivos procedentes del medio hospitalario y extrahospitalario.
Enferm Infecc Microbiol Clin, 23 (2005), pp. 197-201
[21.]
J.A. Lorente Garin, J. Placer Santos, M. Salvado Costa, C. Segura Álvarez, A. Gelabert-Mas.
Evolución de la resistencia antibiótica en las infecciones urinarias adquiridas en la comunidad.
Rev Clin Esp, 205 (2005), pp. 259-264
[22.]
T.M. Hooton, R.H. Latham, E.S. Wong, C. Johnson, P.L. Roberts, W.E. Stamm.
Ofloxacin versus trimethoprim-sulfamethoxazole for treatment of acute cystitis.
Antimicrob Agents Chemother, 33 (1989), pp. 1308-1312
[23.]
E.E. Petersen, F. Wingen, K.L. Fairchild, A. Halfhide, A. Hendrischk, M. Links, et al.
Single dose pefloxacin compared with multiple dose co-trimoxazole in cystitis.
J Antimicrob Chemother, 26 (1990), pp. 147-152
[24.]
M. Jonsson, G. Englund, K. Norgard.
Norfloxacin vs. pivmecillinam in the treatment of uncomplicated lower urinary tract infections in hospitalized elderly patients.
Scand J Infect Dis, 22 (1990), pp. 339-344
[25.]
T. Sandberg, G. Englund, K. Lincoln, L.G. Nilsson.
Randomised double-blind study of norfloxacin and cefadroxil in the treatment of acute pyelonephritis.
Eur J Clin Microbiol Infect Dis, 9 (1990), pp. 317-323
[26.]
T.M. Hooton, D. Scholes, K. Gupta, A.E. Stapleton, P.L. Roberts, W.E. Stamm.
Amoxicillin-clavulanate vs. ciprofloxacin for the treatment of uncomplicated cystitis in women: a randomized trial.
JAMA, 293 (2005), pp. 949-955
[27.]
A. Iravani, A.D. Tice, J. McCarty, D.H. Sikes, T. Nolen, H.A. Gallis, et al.
Short-course ciprofloxacin treatment of acute uncomplicated urinary tract infection in women. The minimum effective dose. The Urinary Tract Infection Study Group.
Arch Intern Med, 155 (1995), pp. 485-494
[28.]
R. Saginur, L.E. Nicolle.
Single-dose compared with 3-day norfloxacin treatment of uncomplicated urinary tract infection in women. Canadian Infectious Diseases Society Clinical Trials Study Group.
Arch Intern Med, 152 (1992), pp. 1233-1237
[29.]
J.I. Alós, M.G. Serrano, J.L. Gómez-Garcés, J. Perianes.
Antibiotic resistance of Escherichia coli from community-acquired urinary tract infections in relation to demographic and clinical data.
Clin Microbiol Infect, 11 (2005), pp. 199-203
[30.]
K.M. Killgore, K.L. March, B.J. Guglielmo.
Risk factors community acquired ciprofloxacin resistant E. coli urinary tract infection.
Ann Pharmacother, 38 (2004), pp. 1148-1152
[31.]
Gupta K, Stamm WE. Urinary tract infections. 2005. Disponible en: http://www.medscape.com/viewarticle/505095
[32.]
T.M. Hooton, R. Besser, B. Foxman, T.R. Fritsche, L.E. Nicolle.
Acute uncomplicated cystitis in an era of increasing antibiotic resistance: a proposed approach to empirical therapy.
Clin Infect Dis, 39 (2004), pp. 75-80
[33.]
K. Gupta, T.M. Hooton, W.E. Stamm.
Isolation of fluorquinolone-resistant rectal Escherichia coli after treatment of acute uncomplicated cystitis.
J Antimicrob Chemother, 56 (2005), pp. 243-246
[34.]
J. Garau, M. Xercavins, M. Rodríguez-Carballeira, J.R. Gómez-Vera, I. Coll, D. Vidal, et al.
Emergence and dissemination of quinolone-resistant Escherichia coli in the community.
Antimicrob Agents Chemother, 43 (1999), pp. 2736-2741
[35.]
J.P. Horcajada, J. Vila, A. Moreno-Martínez, J. Ruiz, J.A. Martínez, M. Sánchez, et al.
Molecular epidemiology and evolution of resistance to quinolones in Escherichia coli after prolonged administration of ciprofloxacin in patients with prostatitis.
J Antimicrob Chemother, 49 (2002), pp. 55-59
[36.]
A. Iravani, G.A. Richard, D. Johnson, A. Bryant.
A double-blind, multicenter, comparative study of the safety and efficacy of cefixime versus amoxicillin in the treatment of acute urinary tract infections in adult patients.
Am J Med, 85 (1988), pp. 17-23
[37.]
C.E. Cox, J.F. Graveline, J.M. Luongo.
Review of clinical experience in the United States with cefpodoxime proxetil in adults with uncomplicated urinary tract infections.
Drugs, 42 (1991), pp. 41-50
[38.]
T.M. Hooton, C. Winter, F. Tiu, W.E. Stamm.
Randomized comparative trial and cost analysis of 3-day antimicrobial regimens for treatment of acute cystitis in women.
JAMA, 273 (1995), pp. 41-45
[39.]
C.E. Nord, G. Movin, D. Stalberg.
Impact of cefixime on the normal intestinal microflora.
Scand J Infect Dis, 20 (1988), pp. 547-552
[40.]
J. Wiener, J.P. Quinn, P.A. Bradford, R.V. Goering, C. Nathan, K. Bush, et al.
Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes.
JAMA, 281 (1999), pp. 517-523
[41.]
J. Rodríguez-Baño, M.D. Navarro, L. Romero, L. Martínez-Martínez, M.A. Muniain, E.J. Perea, et al.
Epidemiology and clinical features of infections caused by extended-spectrum beta-lactamase-producing Escherichia coli in nonhospitalized patients.
J Clin Microbiol, 42 (2004), pp. 1089-1094
[42.]
A. Yague, L. Cebrián, J.C. Rodríguez-Díaz, N. Gonzalo-Jiménez, G. Royo, P. Campillos, et al.
Cepas de Escherichia coli productoras de betalactamasas de espectro extendido: origen, características e incidencia en el sur de la provincia de Alicante en el período 1999-2003.
Enferm Infecc Microbiol Clin, 23 (2005), pp. 76-79
[43.]
J.R. Hernández, A. Pascual, R. Cantón, L. Martínez-Martínez, Grupo de Estudio de Infección Hospitalaria (GEIH).
Escherichia coli y Klebsiella pneumoniae productores de betalactamasas de espectro extendido en hospitales españoles (Proyecto GEIH-BLEE 2000).
Enferm Infecc Microbiol Clin, 21 (2003), pp. 77-82
[44.]
R. Colodner, W. Rock, B. Chazan, N. Keller, N. Guy, W. Sakran, et al.
Risk factors for the development of extended-spectrum beta-lactamase-producing bacteria in nonhospitalized patients.
Eur J Clin Microbiol Infect Dis, 23 (2004), pp. 163-167
[45.]
J.D. Pitout, N.D. Hanson, D.L. Church, K.B. Laupland.
Population-based laboratory surveillance for Escherichia coli-producing extended-spectrum beta-lactamases: importance of community isolates with blaCTX-M genes.
Clin Infect Dis, 38 (2004), pp. 1736-1741
[46.]
J.A. Sigurdsson, J. Ahlmen, L. Berglund, M. Jerneck, L. Larsson, K. Lincoln, et al.
Three-day treatment of acute lower urinary tract infections in women. A double-blind study with amoxicillin and co-trimazine.
Acta Med Scand, 213 (1983), pp. 55-60
[47.]
J. Hamacher, J. Luepke, B.E. Reidenberg, C.E. Nord, K. Borner, P. Koeppe, et al.
Changes in fecal flora and comparative multiple-dose pharmacokinetics of ceftibuten, cefpodoxime proxetil and amoxycillin/clavulanate.
Clin Microbiol Infect, 5 (1999), pp. 339-354
[48.]
G. Samonis, A. Gikas, P. Toloudis, S. Maraki, G. Vrentzos, Y. Tselentis, et al.
Prospective study of the impact of broad-spectrum antibiotics on the yeast flora of the human gut.
Eur J Clin Microbiol Infect Dis, 13 (1994), pp. 665-667
[49.]
G. Elhanan, H. Tabenkin, R. Yahalom, R. Raz.
Single-dose fosfomycin trometamol versus 5-day cephalexin regimen for treatment of uncomplicated lower urinary tract infections in women.
Antimicrob Agents Chemother, 38 (1994), pp. 2612-2614
[50.]
S.S. Patel, J.A. Balfour, H.M. Bryson.
Fosfomycin Tromethamine. A review of its antibacterial activitiy pharmacocinetic properities and therapeutic efficacy as a single-dose oral treatment for acute uncomplicated cystitis.
Drugs, 53 (1997), pp. 637-656
[51.]
L.E. Nicolle.
Urinary tract infections: traditional pharmacologic therapies.
Am J Med, 113 (2002), pp. 35S-44S
[52.]
D.S. Reeves.
Clinical efficacy and safety of fosfomycin trometamol in the prevention and treatment of urinaryt tract infections.
Rev Contemp Pharmacotherap, 6 (1995), pp. 71-83
[53.]
A. Jardin.
A general practitioner multicenter study: fosfomycin trometamol single dose versus pipemidic acid multiple dose.
Infection, 18 (1990), pp. S89-S93
[54.]
J.B. Boerema, F.T. Willems.
Fosfomycin trometamol in a single dose versus norfloxacin for seven days in the treatment of uncomplicated urinary infections in general practice.
Infection, 18 (1990), pp. S80-S88
[55.]
Z. De Jong, F. Pontonnier, P. Plante.
Single-dose fosfomycin trometamol (Monuril) versus multiple-dose norfloxacin: results of a multicenter study in females with uncomplicated lower urinary tract infections.
Urol Int, 46 (1991), pp. 344-348
[56.]
Fosfomycin for urinary tract infections. Med Lett Drugs Ther. 1997; 39: 66-8.
[57.]
G.E. Stein.
Comparison of single-dose fosfomycin and a 7-day course of nitrofurantoin in female patients with uncomplicated urinary tract infection.
Clin Ther, 21 (1999), pp. 1864-1872
[58.]
R. Raz, B. Chazan, Y. Kennes, R. Colodner, E. Rollensterich, M. Dan, et al.
Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with a high prevalence of TMP-SMX-resistant uropathogens.
Clin Infect Dis, 34 (2002), pp. 1165-1169
[59.]
S.R. Norrby.
Short-term treatment of uncomplicated lower urinary tract infections in women.
Rev Infect Dis, 12 (1990), pp. 458-464
[60.]
T.M. Hooton.
The current management strategies for community-acquired urinary tract infection.
Infect Dis Clin N Am, 17 (2003), pp. 303-332
Copyright © 2005. Elsevier España S.L.. Todos los derechos reservados
