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T

AMMI GUIDELINE P APER

Complicated urinary tract infection in adultsLE Nicolle MD FRCP Editor!in!C"ief# $AMMI Canada Guidelines Committee%

LE Nicolle$ AMMI Canada Guidelines Committee&Complicated urinary tract infection in adults& Can ' Infect DisMed Micro(iol )**+,-. .#/012!0.*&

3AC4GR5UND/ Complicated urinary tract infection occurs inindi6iduals 7it" functional or structural a(normalities of t"e 8eni!tourinary tract&53'ECTI9E/ To re6ie7 current :no7led8e rele6ant to complicatedurinary tract infection$ and to pro6ide e6idence!(ased recommenda!tions for mana8ement&MET;5D lesadultes

;Iines scientifi ues& Un pro=et de li8nesdirectrices a t pr par et a fait l o(=et d une r 6ision criti ue par lesmem(res du comit des li8nes directrices de l Association pour lamicro(iolo8ie m dicale et l infectiolo8ie Canada& Les modificationsd coulant de la r 6ision ont t incorpor es au te?te&R les su=ets atteintsd infections urinaires r currentes sont principalement d termin es par l anomalie sous!=acente plut t ue par l infection& Les principes de

prise en c"ar8e incluent un pr lH6ement uniforme d urine en 6ue d uneuroculture a6ant la t" rapie antimicro(ienne$ la caract risation del anomalie 8 nito!urinaire sous! =acente et le non!traitement de la

(act riurie asymptomati ue$ sauf en pr 6ision d une inter6ention8 nito!urinaire effracti6e& Le sc" ma antimicro(ien est d termin par la

pr sentation clini ue$ la tol rance du patient$ la fonction r nale etles or8anismes infectieu? connus ou anticip s&

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012

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Nicolle et al

21 Can ' Infect Dis Med Micro(iol 9ol -. No . No6em(erKDecem(er )**+

TA3LE -ationfrom co"ort or case!controlled analyticalstudies$or from dramatic results of uncontrolled e?periment s

III E6idence from opinions of respected aut"orities t"at is (asedon clinical e?perience$ descripti6e studies or reports ofe?pert committees

Data from reference -

urinary infection )#& For asymptomatic 7omen$ t7o consecu!ti6e urine specimens 7it" t"e same or8anism s# isolated is t"erecommended criteria& Recurrent urinary infection$ eit"er t"rou8" relapse or reinfection$ is common in patients 7"oe?perience complicated urinary infection& A relapse is a recur!rent infection 7it" an or8anism similar to t"e pret"erapy iso!late$ usually follo7in8 persistence of t"e or8anism in t"e8enitourinary tract& A reinfection is a recurrent infection 7it" ane7 or8anism&

C;ARACTERIationUreteric stent

Nep"rostomy tu(eUrolo8ical procedures

Impaired 6oidin8 Neuro8enic (ladderCystocele9esicoureteral reflu?

Ileal conduitMeta(olic a(normalities Nep"rocalcinosis

Medullary spon8e :idneyRenal failure

Immunocompromised Renal transplant

Clinical presentationAsymptomatic urinary infection$ or asymptomatic (acteriuria$is t"e most common clinical presentation of complicated uri!nary infection& In some populations$ t"e pre6alence of (acteri!uria is 6ery "i8"$ reac"in8 -**Q in patients 7it" c"ronic

ind7ellin8 cat"eters +#$ 0*Q to 1*Q in patients 7it" a neuro!8enic (ladder mana8ed (y intermittent cat"eteri>ation J#$ and+*Q in elderly nursin8 "ome residents 2#& T"e clinical

presen! tation of symptomatic infection in patients 7it"complicated urinary infection 6aries across a 7ide spectrum$ran8in8 from mild lo7er tract irritati6e symptoms$ suc" asfre uency and ur8ency$ to se6ere systemic manifestations$suc" as (acteremia and sepsis&Complete urinary o(struction or trauma to t"e (ac! teriuric 8enitourinary tract$ especially 7it""ematuria$ appear to (e associated 7it" more se6ere clinical presentations&

Infectin8 or8anismsA 7ide 6ariety of or8anisms are isolated from patients 7it"complicated urinary infection Ta(le 0# -*!-+#& Esc"eric"iacoli is t"e most common or8anism isolated$ (ut is isolatedmore fre! uently in 7omen t"an in men 2$-.$- #& E colistrains isolated from symptomatic patients 7it" complicatedurinary infection "a6e a lo7er pre6alence of 8enetic or

p"enotypic 6irulence c"aracteristics and are less li:ely toori8inate from a uropat"o! 8enic clone t"an strains isolatedfrom patients 7it" acute uncomplicated infection -J#& T"iso(ser6ation is consistent 7it" t"e "ost a(normality (ein8 t"e

principal determinant of infection$ 7it" or8anism factorsless important& Many ot"er Gram!ne8ati6e or8anisms areisolated from complicated urinary infection Ta(le 0#& Urease!

producin8 or8anisms suc" as Proteus mira(ilis$ Pro6idenciastuartii and Mor8anella mor8anii are com! mon$ especially in

patients 7it" ind7ellin8 urolo8ical de6ices& C"ronic

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Complicated urinary tract infection in adult s

Can ' Infect Dis Med Micro(iol 9ol -. No . No6em(erKDecem(er )**+ 2+

Pseudomonas aeru8inosa infection is pro(lematic for

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C"ronic cat"eter $ Intermittent5r8anism isolated 7omen -*# cat"eter --#

TA3LE 05r8anisms isolated from populations 7it" complicated urinary tract infection UTI#

Population reference#%

ElderlyComplicated

UTI -)# ;ospitali>ed -0#ed

men -+#

Esc"eric"ia coli 02 0+ .* 0+ -* -+

4le(siella pneumoniae )- ). -- -+ N< J&)Proteus mira(ilis ++ -. +&0 &+ . 1)Pro6idencia species +J -* * N< ))Pseudomonas aeru8inosa 0) )0 )&) -) -) )5t"er Gram!ne8ati6e or8anisms 02 0. -2&+ )1 1 2&1Enterococcus species N< -* .&J -&- -) &-Group 3 streptococcus N< -&1 -&- N< )&1Coa8ulase!ne8ati6e st ap"ylococcus N< -&1 -&+ -&- )1 )&15t"er Gram!positi6e or8anisms 02 +&J )&0 *&. 1 0&+

east N< N< N< N< )J N<

%E?pressed as a percenta8e of patients& Patientsmay "a6e more t"an one or8anism isolated, Includes Citro(acter species$ Entero(acter species$ Mor8anellamor8anii$

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fre uency$ ur8ency$ dysuria$ suprapu(ic discomfort$ and ne7or increased incontinence& Acute pyelonep"ritis presents 7it"costo6erte(ral an8le pain or tenderness$ often 7it" fe6er$ and6aria(le lo7er tract symptoms& in8 symptoms is seldom due to urinaryinfection in resi! dents 7it"out a c"ronic ind7ellin8 cat"eter

)J#& Fe6er7it"out locali>in8 findin8s is$ "o7e6er$ a common presentation of uri! nary infection in patients 7it" c"ronicind7ellin8 cat"eters&

Urine cultureA urine specimen for culture o(tained (efore t"e initiationof antimicro(ial t"erapy confirms t"e dia8nosis of urinaryinfec! tion and identifies t"e infectin8 or8anism andsuscepti(ilities& T"e 7ide 6ariety of potential infectin8or8anisms and increased li:eli"ood of more resistantor8anisms ma:es t"e urine culture essential for optimalantimicro(ial mana8ement&A uantitati6e count of at least-* J cfuKLin a 6oided specimen is consistent 7it" infection int"e noncat"eteri>ed patient )#&For a urine specimeno(tained (y in and out cat"eteri>ation$ any uantitati6ecount of a potential uropat"o8en is consid! ered consistent7it" infection& A uantitati6e count of at least-* + cfuKL is sufficient for a micro(iolo8ical dia8nosis in urinespecimens o(tained (y intermittent cat"eteri>ation )2#$ or in patients 7it" s"ort!term 0*# or lon8!term -*#ind7ellin8 cat"eters&

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TA3LE 1Pre6alence of asymptomatic (acteriuria in populations atris: for symptomatic episodes of complicated urinaryinfectionPopulation reference# Pre6alence of (acteriuria Q#

Elderly 2#Community

@omen . -Men -&+ -+

Institutionali>ed

@omen ) +Men -2 0

Cat"eteri>edIntermittent 0-# 0J +Jin8 si8ns or symptoms$ (acteriuria "as only a -*Q

posi! ti6e predicti6e 6alue for a urinary source of fe6er )J#&A ne8! ati6e urine culture$ "o7e6er$ "as a "i8" ne8ati6e predicti6e 6alue$ and is useful to e?clude urinary infection&

Urinalysised (y pyuria&T"us$ pyuria is consistent 7it"$ (ut not dia8nostic of$ urinaryinfection$ and pyuria in t"e (acteriuric patient does notidentify symptomatic infection& T"ere is$ "o7e6er$ a "i8"ne8ati6e predicti6e 6alue for pyuria$ and a urinalysis 7it"out

pyuria may relia(ly e?clude symptomatic urinary infection01$0+#& @"ite (lood cell casts are found on urinalysis in

some su(=ects 7it" renal infection&T"ey are$ "o7e6er$nonspecific$ and present in interstitial nep"ritis and ot"er tu(ulointerstitial disorders 7it" inflamma! tion$ in addition toinfection&

C"aracteri>ation of underlyin8 a(normalityRecurrent infection may (e pre6ented if t"e 8enitourinarya(normality t"at promotes infection can (e corrected& T"ea(normality may (e apparent for e?ample$ a spinal cordin=ury patient mana8ed 7it" intermittent cat"eteri>ation or a

patient 7it" an ileal conduit or nep"rostomy tu(e& @"erecomplicated urinary infection is suspected (ut a(normalities"a6e not (een defined$ a dia8nostic in6esti8ation to c"aracter!i>e t"e potential underlyin8 a(normality is indicated& T"edia8nostic approac" 7ill (e determined (y t"e patient "istory $clinical presentation and access to testin8& Dia8nostic ima8in8may include renal and pel6ic ultrasound$ intra6enous

pyelo8ra! p"y$ computed tomo8rap"y or ma8netic

resonance ima8in8&

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Urolo8ical assessment suc" as cystoscopy$ retro8rade pyelo8ra! p"y or urodynamic studies may also (e indicated&

Patients presentin8 7it" se6ere clinical presentations suc"as sepsis$ or t"ose 7"o fail to respond to initial t"erapy$may re uire ur8ent e6aluation to e?clude an o(structedurinary tract or a(scess$ 7"ic" may re uire draina8e& Men 7"o present 7it" a first urinary infection 7it"out prior 8enitourinary instrumentation fre uently "a6e an a(normalityidentified fol! lo7in8 in6esti8ations .#& For "ealt"y youn87omen 7it" recurrent cystitis or acute pyelonep"ritis$"o7e6er$ in6esti8a! tions "a6e a lo7 dia8nostic yield and arenot routinely recom! mended 0.#& Postmenopausal 7omen7it" a ne7 onset or increased fre uency of recurrentinfection s"ould (e assessed to c"aracteri>e a(normalities$suc" as (ladder di6erticula or cys! toceles #& Recurrentinfection follo7in8 a (ladder suspension or ot"er 8ynecolo8ical sur8ery may su88est (ladder outleto(struction$ and urodynamic studies may (e appropriate&Patients 7it" a pre6iously c"aracteri>ed a(normality andincreased fre uency or se6erity of symptomatic episodes mayre uire repeat e6aluation to e?clude ne7 or pro8ressi6e a(nor!malities&

ANTIMICR53IAL T;ERAPAsymptomatic urinary infectionProspecti6e$ randomi>ed trials of treatment or no treatment of asymptomatic (acteriuria consistently conclude t"at antimicro!

(ial t"erapy for asymptomatic (acteriuria is not (eneficial inmost populations Ta(le +# 0 !11#& Clinical trials "a6e docu!mented no (enefit for t"e treatment of asymptomatic (acteri!uria in su(=ects 7it" c"ronic ind7ellin8 cat"eters 1)#$ elderlymen or 7omen residin8 in nursin8 "omes - $0 !02#$ patients7it" spinal cord in=ury mana8ed 7it" intermittent cat"eteri>a!tion 1-# and 7omen 7it" dia(etes 11#& T"ese studies alsodocument "armful outcomes 7it" antimicro(ial t"erapy $includin8 ad6erse dru8 effects and reinfection 7it" more

resist! ant or8anisms&A prospecti6e$ randomi>ed$ place(o!controlled trial 10#

addressed treatment of asymptomatic cat"eter!ac uired (ac!teriuria persistin8 1J " follo7in8 cat"eter remo6al in 7omen&@it"in -1 days$ 0.Q of place(o recipients "ad spontaneousresolution of (acteriuria$ (ut ).Q of recipients 7it" persist!ent (acteriuria de6eloped symptoms& @omen youn8er t"an.* years of a8e or t"ose infected 7it" Gram!positi6e or8an!isms 7ere more li:ely to "a6e spontaneous resolution& In t"etreatment arm$ sin8le!dose and -*!day trimet"oprim!sulfamet"o?a>ole TMPK

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TA3LE +Prospecti6e$ randomi>ed trials of treatment T# or nontreatment NT# of asymptomatic (acteriuria in patients at ris: of complicated urinary tract infection UTI#

Population reference#Patient sstudied

< tudyduration 5utcomes

Elderly institutionali>ed men -+# -. T$ )* NT )1 mont"s No differences in symptomatic infection or mortalityElderly institutionali>ed 7omen 0 # ). T$ )1 NT -) mont"s No differences in symptomatic UTI$ mortality, 7it" t"erapy$ ad6erse dru8 effects

increase$ and resistance 7it" reinfection increases

Elderly institutionali>ed 7omen 0J# 0+J J&+years No difference in mortalityElderly institutionali>ed 7omen 02# 00 T$ 0J NT 0 days No impro6ement in c"ronic incontinence 7it" anti(iotic treatmentElderly 7omen$ 8eriatric .0 T$ .- NT . mont"s No si8nificant decrease in symptomatic UTI 7it" treatment

apartment 1*#

Intermittent cat"eter 1-# ) NT Mean 1) days ed (y treatment of

asymptomatic (acteriuria to ac"ie6e sterile urine at t"e time of t"e procedure +-!+0#& Conceptually$ t"is is prop"yla?is to

pre6ent sepsis rat"er t"an treatment of asymptomati c (acteriuria& Antimicro(ial t"erapy may (e initiatedimmediately (efore t"e procedure& T"e ran8e of urolo8ical

procedures for 7"ic" pre! treatment is indicated remainscontro6ersial& Treatment is rec! ommended for transuret"ralresection of t"e prostate$ open prostatectomy$ laser

prostatectomy and cystoscopy in men +-#& Cat"eter c"an8ein patients 7it" c"ronic ind7ellin8 cat"eters is seldomassociated 7it" fe6er$ and antimicro(ial treatment (eforec"ronic uret"ral cat"eter replacement is not recommended

+1$++#& Perioperati6e anti(iotics may not pre! 6ent (acteremia accompanyin8 nep"rostomy tu(e replacement +.#&T"e role of antimicro(ial t"erapy to pre6ent complica! tions7it" t"is inter6ention re uires furt"er e6aluation&

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specific t"erapy can (e directed at t"e :no7n pat"o8en&@"ere empirical t"erapy is initiated$ t"e antimicro(ial c"oices"ould (e reassessed once culture results (ecome a6aila(le$usually 7it"in 1J " to ) "&

Many comparati6e clinical trials of treatment of complicatedurinary infection "a6e (een reported& E6aluation of t"ese stud!ies is fre uently compromised (y 6aria(ility in study su(=ects$small sample si>e$lac: of (lindin8 or place(o control$ 6aria(lefollo7!up and e?clusion of patients 7it" resistant isolates&Pu(lis"ed reports in En8lis" descri(in8 comparati6e studies of ade uate sample si>e 7it" at least s"ort!term follo7!up fi6e tonine days post!t"erapy# are summari>ed in Ta(le . + !J1#&

T"ese studies 8enerally report e ui6alent outcomes for t"ecomparati6e arms& 3ecause patients 7it" resistant isolates areusually e?cluded from e6aluation$ t"e rele6ance of t"ese stud!ies to empirical anti(iotic t"erapy is not clear& Most reportscompare t7o fluoro uinolone antimicro(ials or a fluoro!

uinolone 7it" an antimicro(ial of anot"er class&Comparati6etrials of fluoro uinolones usually report e ui6alence$ (utsparflo?acin 7as found to (e less effecti6e t"an ciproflo?acin ats"ort!term outcome in one study *#& ed rat"er t"an e?creted in t"e urine$ su88estin8 t"atfluoro uinolones t"at ac"ie6e "i8" urinary le6els are preferredfor treatment& Norflo?acin$ 7"ic" "as lo7 tissue le6els (ut"i8" urinary le6els$ 7as as effecti6e as ot"er fluoro uinolonest"at ac"ie6e "i8"er tissue le6els +*$ +! #& In t7o reportedstudies 0$J*#$ treatment 7it" a fluoro uinolone 7as superior to TMPK

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Trial reference# Re8imens n# Micro Clin Micro Clin Comment s

3linded$ ITT + # Pruliflo?acin .** m8 od$ -* d 2J#, 2J&** 21&J* J)&0* J0&1*Ciproflo?acin +** m8 (id$ -* d -*J# 20&+* 20&0* 2&-* J)&-*

3linded$ ITT +J# Ciproflo?acin - 8 od ER$ d -1 d 0 2#, J2&)* J2&2* . &J* .& *Ciproflo?acin +** m8 (id$ d -1 d 1* # J-&1* JJ&2* ++&)* 0&1*

3linded$ ITT +2# Gatiflo?acin )** m8 od$ + d -1 d ) 1#, &** .2&** *&** -&**Pyelonep"ritis$0*Q of su(=ectsGatiflo?acin 1** m8 od$ + d -+ d )J*#, J&** *&** -&** *&**Ciproflo?acin +** m8 (id$ + d -1 d ).2# 0&** .+&** .2&** 1&**

5pen .*# Ciproflo?acin +** m8 (id$ ) 7ee:s 0J#, J2&** 2)&** +&** J0&**Men only$ presentin8 7it" fe6er and UTICiproflo?acin +** m8 (id$ 1 7ee:s 1# 2 &** 2)&** J+&** JJ&**

3linded .-# Ertapenem - 8 od 0 d oral, J+&.* J+&.* N< N< Pyelonep"ritis$ +)Q of su(=ectsCeftria?one - 8 od 0 d oral J1&2* J1&2* N< N<

3linded$ suscepti(le Gatiflo?acin 1** m8 od$ d -* d -J2#, 2)&** 2)&** +&** J1&**only .)# Ciproflo?acin +** m8 (id$ d -* d -J0# J0&** 20&** .0&** 1&**

3linded$ suscepti(le Ertapenem - 8 od$ 0 days% J#, 2)&** N< +&** N< %5ral ciproflo?acinonly .0# Ceftria?one - 8 od$ 0 days% 2*# 20&** N< J&** N<

3linded$ ITT .1# P i pe r a cillinKta>o(act am ) 8K*&+ 8 J"$ +d -1d -.-#, + &J* J0&** 12&-* .+&)*Pyelonep"ritis$-)Q su(=ectsImipenem +** m8 J"$ + d -1 d -..# 1J&.* 2&2* 1J&.* ..&2*

3linded Ciproflo?acin )+* m8 (id$ d )-1#, 2*&-* 2 &)* &-* J & *@omen only$ post!menopausal place(o$ ITT .+# 5flo?acin )** m8 (id$ d JJ# J &)* 2 &)* .&-* J &0*

ITT ..# Ciproflo?acin +** m8 od$ d )* d +#, J1&** 2 &0* &J* J)&**idime - 8 I9 -)" + d 0*0# J &** J)&-* . N<

TA3LE .Comparati6e clinical trials of complicated urinary tract infection UTI#

5utcomes Q cured#

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TA3LE . C5NTINUEDComparati6e clinical trials of complicated urinary tract infection UTI#

5utcomes Q cured#

idime patients "ad renalfailure at enrollment PX*&*-J#,

Cefta>idime +** m8 I9 J" 1 d% 02# J &** 2)&** JJ N< one - 8 to ) 8 -)"$ + d --.# +.&**% N< N< N<3linded J1# Cefopera>one - 8 (id$ + d --.#, .J&)*% +2&+*% N< N< %PY*&*+

Car(enicillin ) 8 (id$ + d --.# +*&** 0*&)* N< N<

(id T7ice a day, Clin Clinical, d Days, ER E?tended release, ITT Intent to treat, I9 Intra6enous, Micro Micro(iolo8ical, N< Not stated, od 5nce daily, po 3y mout",." E6ery si? "ours, J" E6ery ei8"t "ours, -)" E6ery -) "ours, TMPKole

Patients 7it" symptomatic infection can usually (e treated7it" oral t"erapy J+#& Patients 7"o are "emodynamicallyunsta(le$ una(le to tolerate oral medication$ or in 7"om 8as!trointestinal a(sorption is impaired$ re uire parenteral t"erapy&Clinical trials of parenteral t"erapy for complicated urinary

infection "a6e reported efficacy for a 7ide 6ariety of a8ents$ (ut t"ere are limited comparati6e studies& Amino8lycosides2$J0$J.#$ fluoro uinolones 1$ 2$J+$J #$ piperacillinK

ta>o(actam .1$JJ$J2#$ cefta>idime 1$ J$J*$J)# and car! (apenems .-$.1$ -$J)# "a6e all (een reported to ac"ie6e"i8" rates of clinical and micro(iolo8ical cure&Duration of t"erapy/ T"e optimal duration of antimicro(ialt"erapy for t"e treatment of acute symptomatic episodes "asnot (een systematically studied& 3ecause of t"e 7ide6ariation in underlyin8 a(normalities and clinical

presentations$ a uni! form recommendation for treatmentduration is li:ely not appropriate& Most clinical trials"a6e e6aluated se6en to-1 days of t"erapy$ (ut as s"ort as fi6e days and as lon8 as )*days "a6e (een reported Ta(le .#& A prospecti6erandomi>ed clinical trial 2*# of t"ree or -1 days of ciproflo?acin t"erapy in spinal cord in=ury patients reportedfe7er symptomatic relaps! es post!t"erapy 7it" t"e -1!daytreatment& In anot"er prospec! ti6e randomi>ed trial$ men

presentin8 7it" fe(rile urinary tract infection "ad similar outcomes 7it" eit"er t7o or four 7ee:s of ciproflo?acint"erapy .*#& A se6en!day re8imen is currently su88ested for

patients presentin8 7it" symptoms consistent 7it" lo7er tract infection$ and a lon8er course of -* to -1 days isrecommended for patients 7it" more se6ere presentationsmanifested (y fe6er$ (acteremia or "ypotension&Anticipated outcome/ T"e natural "istory of untreatedsymp! tomatic complicated urinary infection "as not (eenreported&

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Patients 7"o fail to respond in t"is time frame s"ould (ereassessed to e?clude urinary o(struction or a(scess 7"ic"may re uire draina8e#$ to e?clude resistance of t"e infectin8or8anism to t"e antimicro(ial a8ent$ or to consider an alter!nate dia8nosis ot"er t"an urinary infection& @"en t"e 8eni!tourinary a(normality predisposin8 to infection persists$ a "i8"fre uency of recurrent infection is anticipated$ usually at least+*Q (y si? 7ee:s post!t"erapy 0$-)$2-#& Recurrent infectionmay (e eit"er symptomatic or asymptomatic& Post!t"erapyrecurrence usually depends on 7"et"er t"e underlyin8 a(nor!mality is still present& Resistance of t"e pret"erapy!infectin8or8anism to t"e antimicro(ial used for treatment is alsoassoci! ated 7it" failure or relapse .)#&

Lon8!term t"erapy

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and clinical outcomes 7it" a re8imen of norflo?acin 1** m8t7ice a day for one mont" follo7ed (y an additional t7omont"s of eit"er 1** m8 once daily or continuin8 full dose&T"us$ at least for norflo?acin$ prolon8ed suppressi6e t"erapy is

(eneficial for selected comple? patients 7it" recurrent infec!tion$ and t"erapy remains effecti6e if continued at a reduceddose after an initial period of full!dose t"erapy&

Uni ue populationsUrolo8ical de6ices/ Urolo8ical de6ices t"at remain in situ$suc" as ind7ellin8 uret"ral cat"eters$ ureteric stents andnep"rostomy tu(es$ rapidly (ecome coated 7it" a (iofilm 1#&T"is (iofilm contains a "i8" concentration of microor8anisms$ particularly urease!producin8 or8anismssuc" as P mira(ilis $ M mor8anii or Pro6idencia species&5r8anisms 8ro7in8 in t"e (iofilm are relati6ely protectedfrom (ot" antimicro(ials and "ost defenses& T"e (iofilm$7"ic" is a reser6oir for or8anisms$ causes relapsin8 infection

post!treatment$ and infectin8 or8an! isms (ecome increasin8lyresistant to antimicro(ials 7it" repeated courses of antimicro(ial t"erapy 2#& Replacement of a c"ronicind7ellin8 cat"eter (efore initiatin8 antimicro(ial t"erapy for symptomatic urinary infection results in a more rapiddefer6escence of fe6er and decreased incidence of s"ort! termsymptomatic relapse )-#& T"is su88ests t"ere is a clinical

(enefit associated 7it" t"e remo6al of (iofilm!laden de6ices (efore initiatin8 t"erapy for symptomatic patients&Resistant (acteria/ Patients 7it" fre uent recurrent infectionmay e?perience reinfection 7it" pro8ressi6ely resistant or8an!isms$ 7it" concomitant decrease in t"erapeutic options for su(se uent infections 2+#& P aeru8inosa is particularly pro(!lematic in some patients 2.$2 #& Mucoid strains "i8"ly resist!ant to multiple antimicro(ials$ reminiscent of lun8 isolatesfrom cystic fi(rosis patients$ may (e isolated& Antimicro(ial

t"erapy for t"e treatment of "i8"ly resistant or8anisms must (edirected (y or8anism suscepti(ility& Parenteral t"erapy is nec!essary 7"en infectin8 or8anisms are no lon8er suscepti(le toa6aila(le oral a8ents 2.!2J#&Fun8al urinary infection/ Fun8al urinary infection is usuallyidentified in patients 7"o are dia(etic$ "a6e ind7ellin8 ure!t"ral cat"eters or ot"er urolo8ical de6ices$ and "a6e recei6ed

(road!spectrum antimicro(ial t"erapy 22#& Candida al(icans ist"e most common isolate& Candida 8la(rata is t"e second mostfre uent species 22#$ and may (e increasin8 7it" t"e 7ide!spread use of a>oles$ to 7"ic" t"is species is less suscepti(le

-**#& A prospecti6e$ randomi>ed$ place(o!controlled clinicaltrial -*-# reported no clinical (enefits 7it" t"e treatment of asymptomatic fun8uria& Most episodes of fun8uria in patients7it" an ind7ellin8 cat"eter 7ill resol6e spontaneouslyfollo7! in8 cat"eter remo6al&

3ot" a>oles and amp"otericin 3 are effecti6e for t"e treat!ment of symptomatic fun8al urinary infection -*)!-*1#&Amp"otericin 3 (ladder 7as"out is as effecti6e as s"ort!course systemic amp"otericin 3 for t"e treatment of (ladder infection (ut re uires an ind7ellin8 uret"ral cat"eter andrestricts mo(ility, as suc"$ it is no7 seldom used -*)#&Flucona>ole is as effecti6e as amp"otericin 3 (ladder irri8ation for t"e treatment of fun8uria -*0$-*1#& Flucona>oleis e?creted in t"e urine and is t"e preferred a>ole$ alt"ou8"comparati6e trials of t"is a8ent 7it" itracona>ole$:etocona>ole or 6oricona>ole are not reported& Non!al(icansCandida species may "a6e increased resistance to a>oles$andsystemic amp"otericin 3 may (e nec! essary to treat

infection 7it" some of t"ese species&

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ac uisition in patients 7it" ind7ellin8 cat"eters -)-!-)0#&Future de6elopments in cat"eter (iomaterials to in"i(it

(iofilm formation may limit (iofilm!associated infections$ (ut (enefits from t"is approac" "a6e not yet (een reali>ed for clin!ical practice -)1#&

REC5MMENDA TI5N<Dia8nosisT"e dia8nosis of symptomatic urinary tract infection in

patients 7it"out ind7ellin8 urolo8ical de6ices s"ould (e con!sidered only 7"en locali>in8 8enitourinary si8ns or symptoms are present AII#&-& For patients 7it" ind7ellin8 urolo8ical de6ices$

systemic symptoms$ suc" as fe6er in t"e a(sence oflocali>in8 8enitourinary si8ns and symptoms$ may (econsistent 7it" symptomatic urinary tract infection

AII#&

)& A urine specimen s"ould (e o(tained for culture andsuscepti(ility testin8 (efore institution of antimicro(ialt"erapy for e6ery episode of complicated urinary tract

infection AI#&Z A sin8le urine specimen 7it" a uantitati6e count of

at least -* J cfuKL at least -*+ cfuKmL# isconsistent7it" urinary infection in symptomatic su(=ects AII#&

Z A uantitati6e count of at least -* J cfuKL at least-* + cfuKmL# on t7o consecuti6e specimens is t"eappropriate dia8nostic criteria to identifyasymptomatic (acteriuria in 7omen 3II#&

Z Any uantitati6e count of or8anisms is consistent7it" (acteriuria for indi6iduals 7it" urine specimenso(tained (y (ladder cat"eteri>ation AII#&

Treatment-&

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.& Parenteral t"erapy is indicated if patients are una(le totolerate oral t"erapy$ "a6e impaired 8astrointestinala(sorption$ "a6e "emodynamic insta(ility$ or if t"einfectin8 or8anism is :no7n or suspected to (e resistantto oral a8ents AI#&

& T"e duration of t"erapy s"ould (e se6en days for indi6iduals 7it" lo7er tract symptoms$ and -* to-1 days for indi6iduals presentin8 7it" upper tractsymptoms or sepsis syndrome 3III#&

Z Patients 7it" c"ronic urolo8ical de6ices s"ouldrecei6e as s"ort a duration of t"erapy as possi(le tolimit antimicro(ial pressure leadin8 to resistanceemer8ence AIII#&

J& A urine culture to document (acteriolo8ical cure after treatment is not recommended if t"e patient isasymptomatic 3II#&

In6esti8ations-& Patients presentin8 7it" symptomatic urinary infection

7"o may "a6e complicated urinary infection$ includin8male patients of any a8e$ older 7omen$ and any 7oman

7it" recurrent symptomatic episodes presentin8 7it"systemic manifestations$ s"ould "a6e 8enitourinaryin6esti8ations to c"aracteri>e t"e structural andfunctional status of t"e 8enitourinary tract AII#&

)& Patients 7"o fail to respond to t"erapy or 7"o present7it" se6ere manifestations$ includin8 sepsis syndrome$s"ould "a6e ur8ent e6aluation 7it" ima8in8 to e?cludeo(struction$ a(scess or ot"er a(normalities re uirin8immediate inter6ention AII#&

Pre6ention-& @"ere6er possi(le$ underlyin8 8enitourinary

a(normalities s"ould (e corrected AII#&

)& Prop"ylactic antimicro(ial t"erapy to pre6ent recurrenturinary tract infection is not recommended for patients7it" complicated urinary tract infection AI#&

0&ation in su(=ects 7it"c"ronic ind7ellin8 cat"eters s"ould (e re!e6aluated onan on8oin8 (asis AIII#&

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-J& Nicolle LE& Urinary tract pat"o8ens in complicated infection andin elderly indi6iduals& ' Infect Dis )**-,-J0 ed elderly& Am ' Med -22.,-**/ -! &)2& Gri((le M'$ McCallum NM$ LA$ Glynn R'$ C"oodno6s:iy I$ A6orn'&Epidemiolo8ic and dia8nostic aspects of (acteriuria/A lon8itudinal study in older 7omen& ' Am Geriatr edcomparison of t"erapy and no t"erapy for asymptomatic (acteriuria ininstitutionali>ed 7omen& Am ' Med -2J ,J0/) !00&

0J& A(rutyn E$Mossey

'$ 3erlin 'A$ et al& Does asymptomatic (acteriuria

predict mortality and does antimicro(ial treatment reduce mortalityin elderly am(ulatory 7omen[ Ann Intern Med -221,-)*/J) !00&

Erratum in -221,-)-/2*-#&02& 5uslander 'G$ ed 7omen& 'AMA-2J ,)+ /-*.)! -&

1-& Mo"ler 'L$ Co7en DL$ Flani8an RC& ed neuro8enic (ladder& ' Urol -2J ,-0J/00.!1*&

1)& @arren '@$ Ant"ony @C$ ;oopes 'M$ Muncie ;L 'r& Cep"ale?infor suscepti(le (acteriuria in afe(rile$ lon8!term cat"eteri>ed patients&'AMA -2J),)1J/1+1!J&

10& ;ardin8 G4$ Nicolle LE$ Ronald AR$ et al& ;o7 lon8 s"ouldcat"eter!ac uired urinary tract infection in 7omen (e

treated[A randomi>ed controlled study& Ann Intern Med -22-,--1/ -0!2&

11& ;ardin8 G4M$ \"anel GG$ Nicolle LE$ C"ean8 M, Manito(aDia(etic Urinary Infection

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1+& e: ;E$ Grot" CG& Urinary tractinfections follo7in8 renal transplantation& Clin Transplant-22J,-)/-2!)0&

12& Lyero6a L$ Lac"a '$ er T$ Frei R$ @idmer AF$ et al&Lo7 ris: of (acteremiadurin8 cat"eter replacement in patients 7it" lon8!term urinarycat"eters&Arc" Intern Med -22 ,-+ /+)-!+&

+.& Cronan ''$ ;orn DL$ Marcello A$ et al& Anti(iotics and nep"rostomytu(e care/ Preliminary o(ser6ations& Part II& 3acteremia& Radiolo8y-2J2,- )/-*10!+&

+ & Carmi8nani G$ De Rose AF$ 5li6ieri L$ ed$ dou(le! (lind multicenter comparison of 8atiflo?acin 6s ciproflo?acin in t"etreatment of complicated urinary tract infection and pyelonep"ritis&Clin T"er )**),)1/))0!0.&

.0& Tomera 4M$ 3urdmann EA$ Pamo Reyna 5G$ et al& Ertapenem6ersus ceftria?one follo7ed (y appropriate oral t"erapy for treatmentof complicated urinary tract infections in adults/ Results of a

prospecti6e$ randomi>ed dou(le!(lind multicenter study& Antimicro(A8ents C"emot"er )**),1./)J2+!2**&

.1& Na(er 4G$

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. & 4lim(er8 I@$ Co? CE II$ Fo7ler CL$ 4in8 @$ 4im

& Pittman @$ Moon '5$ ;amric: LC 'r$ et al& Randomi>ed dou(le! (lind trial of "i8"! and lo7!dose flero?acin 6ersus norflo?acin forcomplicated urinary tract infection& Am ' Med -220/21 0A#/-*-

J& Cefpirome 6ersus cefta>idime in t"e treatment of urinary tractinfections& ' Antimicro( C"emot"er -22),)2 ed$ dou(le!(lind comparison of cefta>idimeand mo?alactam in complicated urinary tract infections& Antimicro(A8ents C"emot"er -2J+,)J/)22!0*-&

J0& 3ailey RR$ Peddie 3A$ Lynn 4L$

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