Many experts support using ciprofloxacin as an alternative and, in some cases, as the preferred first-line agent. However, others caution that widespread use of ciprofloxacin will promote increased resistance. Uncomplicated urinary tract infections UTIs are one of the most common diagnoses in the United States.
In , an estimated 8. Streamlining the diagnostic process could also decrease morbidity and improve patient outcomes and satisfaction. Fluoroquinolones are not recommended as first-line treatment of uncomplicated UTIs in order to preserve their effectiveness for complicated UTIs.
Use of betalactam antibiotics is not recommended for the routine treatment of uncomplicated UTIs because of limited effectiveness. For treatment of uncomplicated urinary tract infections in older women, consider short or longer three to 10 days courses of antibiotics. Escherichia coli is the most common cause of uncomplicated UTI and accounts for approximately 75 to 95 percent of all infections.
Staphylococcus saprophyticus is a distant second, accounting for only 5 to 20 percent of infections. Approximately one half of patients infected with S.
Uncomplicated UTI occurs in patients who have a normal, unobstructed genitourinary tract, who have no history of recent instrumentation, and whose symptoms are confined to the lower urinary tract.
Uncomplicated UTIs are most common in young, sexually active women. Fever or costovertebral angle tenderness indicates upper urinary tract involvement. Studies show that no laboratory tests, including urinalysis and culture, can predict clinical outcomes in women 18 to 70 years of age who present with acute dysuria or urgency. Leukocyte esterase is specific 94 to 98 percent and reliably sensitive 75 to 96 percent for detecting uropathogens equivalent to , colonyforming units CFU per mL of urine.
Therefore, the sensitivity of nitrite tests ranges from 35 to 85 percent, but the specificity is 95 percent. Routine urine cultures are not necessary because of the predictable nature of the causative bacteria. However, urinalysis may be appropriate for patients who fail initial treatment. Current literature suggests that a colony count of CFU per mL has a sensitivity of 95 percent and a specificity of 85 percent, 3 but the Infectious Diseases Society of America IDSA recommends using a colony count of 1, CFU per mL 80 percent sensitivity and 90 percent specificity for symptomatic patients.
Physicians may have to request that sensitivities be performed on low-count bacteria if low counts are not the standard in their community.
After reviewing existing data on uncomplicated cystitis, the Group Health Cooperative of Puget Sound implemented evidence—based guidelines for treating adult women with acute dysuria or urgency. These guidelines have reduced doctor visits and laboratory tests without increasing adverse outcomes. Many studies in the last decade have focused on the treatment length of standard therapies. All three medications had similar eradication rates immediately after therapy.
The article 14 also reported that E. Among the tested antimicrobials, E. Of the more than 38, isolates, 7. The Pacific and Mountain regions had a Fluoroquinolones have become popular treatments for patients with uncomplicated UTI because of E. The reported resistance rate of E. A study 18 comparing multidose regimens of ciprofloxacin showed that the minimal effective dosage was mg twice daily. Another study 19 compared a single mg dose of gatifloxacin Tequin , with three-day regimens of gatif loxacin mg twice daily and ciprof loxacin mg twice daily.
The single-dose therapy had a clinical response rate equivalent to the two three-day regimens. Gatifloxacin is also expected to be 1, times less likely than older fluoroquinolones to become resistant because of its 8-methoxy structure. Fosfomycin Monurol is another treatment option for patients with UTI.
The U. A study 20 comparing a single dose of fosfomycin 3 g with a seven-day course of nitrofurantoin mg twice daily showed similar bacteriologic cure rates 60 versus 59 percent, respectively. Increasing resistance, however, has limited their effectiveness. Cephalosporins are pregnancy category B drugs, and a seven-day regimen can be considered as a second-line therapy for pregnant women. Ciprofloxacin Cipro.
Gatifloxacin Tequin. Physicians commonly recommend nonpharmacologic options e. A Cochrane review 22 found insufficient evidence to recommend the use of cranberry juice to manage UTI. Similarly, no scientific evidence suggests that women with cystitis should increase their fluid intake, and some doctors speculate that increased fluid may be detrimental because it may decrease the urinary concentration of antimicrobial agents. Treating older women who have UTIs requires special consideration.
The study, which included outpatient and institutionalized women with an average age of approximately 80 years, showed a 96 percent bacteriologic eradication rate with ciprofloxacin compared with an 80 percent eradication rate with TMP-SMX for the three most common isolates.
The three-day therapy had a higher failure rate when compared with the seven-day regimen. The incidence of UTI in men ages 15 to 50 years is very low, and little evidence exists on treating them. Risk factors include homosexuality, intercourse with an infected woman, and lack of circumcision.
The limited available data are similar on two key points. First, the data show that men should receive the same treatment as women with the exception of nitrofurantoin, which has poor tissue penetration. After reviewing the available clinical data as of and classifying it by quality of evidence, the IDSA published guidelines for the use of antimicrobial agents to treat women with UTI.
Second, although it recognizes that they have efficacy rates similar to TMP-SMX, the IDSA does not recommend fluoroquinolones as universal first-line agents because of resistance concerns. Third, the IDSA recommends a seven-day course of nitrofurantoin or a single dose of fosfomycin as reasonable treatment alternatives. Finally, the IDSA does not recommend the use of betalactams because multiple studies have shown them to be inferior when compared with other treatments.
Figure 1 is an algorithm for the management of uncomplicated UTIs. Algorithm for the management of uncomplicated urinary tract infections. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. She received her medical degree at the University of Oklahoma College of Medicine-Tulsa, where she also completed a family medicine residency. Address correspondence to Susan A.
Mehnert-Kay, M. Louis Ave. Reprints are not available from the author. The author thanks Karen Malnar, R. National Institutes of Health. Nicolle LE. Urinary tract infection: traditional pharmacologic therapies.
Dis Mon. Faro S, Fenner DE. Drugs » Infectious Diseases. Susceptible infections including UTIs not for initial uncomplicated episodes , shigellosis, prophylaxis and treatment of Pneumocystis jiroveci pneumonia PJP , travelers' diarrhea or acute exacerbations of chronic bronchitis in adults, acute otitis media in children. Megaloblastic anemia due to folate deficiency.
Marked hepatic damage. Severe renal insufficiency when renal status cannot be monitored. Concomitant dofetilide. Avoid prolonged administration. Monitor CBCs, urine, and renal function. Hepatic or renal impairment. AIDS increased risk of toxicities. Folate or G6PD deficiency. Severe allergy or bronchial asthma. Circulatory shock. Porphyria or thyroid dysfunction.
Disorders of potassium metabolism. Monitor for electrolyte abnormalities, hematologic toxicity. Maintain adequate hydration.
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