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New Guidelines for Management of Urinary Tract Infection

Модератор: Алексей Живов

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Ren_Yumi
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New Guidelines for Management of Urinary Tract Infection

Сообщение Ren_Yumi » Пт июл 11, 2008 5:02 am

New Guidelines for Management of Urinary Tract Infection in Nonpregnant Women

Obstetrics and Gynecology.2008; 111: 785-794


Specific practice recommendations and their accompanying level of scientific evidence are as follows:

* In nonpregnant, premenopausal women, screening for and treatment of asymptomatic bacteriuria is not recommended (level of evidence, A).

* Antibiotic class should be changed when resistance rates are higher than 15% to 20% (level of evidence, A).

* Patients with acute pyelonephritis should complete 14 days of total antimicrobial therapy, regardless of whether treatment is on an inpatient or outpatient basis (level of evidence, A).

* For uncomplicated acute bacterial cystitis in women, including women 65 years and older, antibiotics should be administered for 3 days (level of evidence, A).

* Urine culture is not required for the initial treatment of a symptomatic lower UTI with pyuria or bacteriuria, or both (level of evidence, B).

* For the treatment of acute uncomplicated cystitis, beta-lactams, including first-generation cephalosporins and amoxicillin, are less effective than the preferred antimicrobials listed as treatment regimens (level of evidence, C).

* For the diagnosis of bacteriuria in symptomatic patients, decreasing the colony count to 1000 to 10,000 bacteria per milliliter will improve sensitivity without significantly reducing specificity (level of evidence, C).

A proposed performance measure is the percentage of women diagnosed with acute pyelonephritis who receive antimicrobial treatment for 14 days.

For uncomplicated acute bacterial cystitis, recommended treatment regimens are as follows:

* Trimethoprim–sulfamethoxazole: 1 tablet (160 mg trimethoprim–800 mg sulfamethoxazole) twice daily for 3 days. Adverse effects may include fever, rash, photosensitivity, neutropenia, thrombocytopenia, anorexia, nausea and vomiting, pruritus, headache, urticaria, Stevens-Johnson syndrome, and toxic epidermal necrosis.

* Trimethoprim 100 mg twice daily for 3 days. Adverse effects may include rash, pruritus, photosensitivity, exfoliative dermatitis, Stevens-Johnson syndrome, toxic epidermal necrosis, and aseptic meningitis.

* Ciprofloxacin 250 mg twice daily for 3 days, levofloxacin 250 mg once daily for 3 days, norfloxacin 400 mg twice daily for 3 days, or gatifloxacin 200 mg, once daily for 3 days. Adverse effects may include rash, confusion, seizures, restlessness, headache, severe hypersensitivity, hypoglycemia, hyperglycemia, and Achilles tendon rupture (in patients older than 60 years).

* Nitrofurantoin macrocrystals 50 to 100 mg 4 times daily for 7 days, or nitrofurantoin monohydrate 100 mg twice daily for 7 days. Adverse effects may include anorexia, nausea, vomiting, hypersensitivity, peripheral neuropathy, hepatitis, hemolytic anemia, and pulmonary reactions.

* Fosfomycin tromethamine, 3-g dose (powder) single dose. Adverse effects may include diarrhea, nausea, vomiting, rash, and hypersensitivity.


Study Highlights


* Screening for and treatment of asymptomatic bacteriuria is not recommended in nonpregnant, premenopausal women.
* When resistance rates are more than 15% to 20%, antibiotic class should be changed.
* For acute pyelonephritis, inpatient or outpatient treatment should continue for 14 days.
* Women with uncomplicated acute bacterial cystitis, including women 65 years or older, should receive antibiotics for 3 days.
* For initial treatment of symptomatic lower UTI with pyuria, bacteriuria, or both, urine culture is not required.
* For treatment of acute uncomplicated cystitis, beta-lactams, including first-generation cephalosporins and amoxicillin, are less effective than the preferred antimicrobials listed as treatment regimens.
* To diagnose bacteriuria in symptomatic patients, decreasing the colony count to 1000 to 10,000 bacteria per milliliter will improve sensitivity without significantly reducing specificity.
* A proposed performance measure is the percentage of women diagnosed with acute pyelonephritis who receive antimicrobial treatment for 14 days.
* For uncomplicated acute bacterial cystitis, recommended treatment regimens are as follows:
o Trimethoprim–sulfamethoxazole: 1 tablet (160 mg trimethoprim–800 mg sulfamethoxazole) twice daily for 3 days. Adverse effects may include fever, rash, photosensitivity, neutropenia, thrombocytopenia, anorexia, nausea and vomiting, pruritus, headache, urticaria, Stevens-Johnson syndrome, and toxic epidermal necrosis.
o Trimethoprim 100 mg twice daily for 3 days. Adverse effects may include rash, pruritus, photosensitivity, exfoliative dermatitis, Stevens-Johnson syndrome, toxic epidermal necrosis, and aseptic meningitis.
o Ciprofloxacin 250 mg twice daily for 3 days, levofloxacin 250 mg once daily for 3 days, norfloxacin 400 mg twice daily for 3 days, or gatifloxacin 200 mg once daily for 3 days. Adverse effects may include rash, confusion, seizures, restlessness, headache, severe hypersensitivity, hypoglycemia, hyperglycemia, and Achilles tendon rupture (in patients older than 60 years).
o Nitrofurantoin macrocrystals 50 to 100 mg 4 times daily for 7 days, or nitrofurantoin monohydrate 100 mg twice daily for 7 days. Adverse effects may include anorexia, nausea, vomiting, hypersensitivity, peripheral neuropathy, hepatitis, hemolytic anemia, and pulmonary reactions.
o Fosfomycin tromethamine 3-g dose (powder) single dose. Adverse effects may include diarrhea, nausea, vomiting, rash, and hypersensitivity.
* For uncomplicated acute bacterial cystitis in women, use of trimethoprim–sulfamethoxazole for 3 days is the preferred therapy, with a 94% bacterial eradication rate. In areas where resistance to this antimicrobial agent is more than 15% to 20%, another of the listed regimens should be chosen.
* For women with frequent recurrences of lower UTI, continuous prophylaxis decreases recurrence risk by 95%.
* Suitable prophylactic regimens for recurrent lower UTI include once-daily treatment with nitrofurantoin, norfloxacin, ciprofloxacin, trimethoprim, trimethoprim–sulfamethoxazole, or another antimicrobial agent listed.
* The need for continued prophylaxis can be re-evaluated after 6 to 12 months.
* Acute pyelonephritis traditionally has been treated with hospitalization and parenteral antibiotics. However, cost-savings measures have prompted a recent shift to outpatient management, whenever feasible.



Pearls for Practice

* Screening for and treatment of asymptomatic bacteriuria is not recommended in nonpregnant, premenopausal women. For acute pyelonephritis, inpatient or outpatient treatment should continue for 14 days. Women with uncomplicated acute bacterial cystitis, including women 65 years or older, should receive antibiotics for 3 days.
* For uncomplicated acute bacterial cystitis in nonpregnant women, the preferred therapy is trimethoprim–sulfamethoxazole twice daily for 3 days. In areas where resistance to this antimicrobial agent is more than 15% to 20%, another regimen should be chosen.

http://www.greenjournal.org/cgi/reprint/111/3/785
http://www.medscape.com/viewarticle/571 ... c=119209BZ
http://www.antibiotic.ru/index.php?article=1667

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