Κατευθυντήριες οδηγίες για ανεπίπλοκες ουρολοιμώξεις.

[Argirios Argiriou]

November 18, 2014
Evidence-Based Recommendations for Diagnosing and Treating Uncomplicated Urinary Tract Infections
Thomas L. Schwenk, MD reviewing Grigoryan L et al. JAMA 2014 Oct 22/29.

UTIs can be diagnosed without office visits or urine cultures; treatment with simple first-line antibiotics is best.

To address best practices on outpatient diagnosis and treatment of urinary tract infections (UTIs) in light of concern about increasing antibiotic resistance, researchers conducted an evidence review of 44 randomized, controlled trials; observational cohort studies; and systematic reviews. These studies focused largely on uncomplicated UTIs in younger women (age, ≤65). Key findings from the evidence review are:

    UTIs can be diagnosed in patients without known anatomic urinary tract abnormalities, recent urinary tract instrumentation, or systemic illness if they exhibit at least two of three cardinal symptoms — dysuria, urgency, or frequency — along with absence of vaginal discharge.

    Neither urine dipstick testing for leukocyte esterase nor urine culture enhances diagnostic sensitivity. ( !! )

    Telephone-based protocols have outcomes similar to office-based diagnosis and treatment, and such methods often are preferred by patients. Patients with histories of uncomplicated UTIs can be taught to self-diagnose and initiate therapy. ( !!! )

    The most appropriate antibiotic choices are trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 to 7 days), nitrofurantoin (100 mg twice daily for 5 to 7 days), or fosfomycin (Monurol; 3 g in a single dose; used rarely by U.S. physicians and much more expensive than the other choices). Fluoroquinolones offered no advantage in cure rates; β-lactam antibiotics, such as amoxicillin-clavulanate, are less effective than the first-line recommendations. Most patients who delay antibiotic treatment to encourage spontaneous resolution eventually receive antibiotics and have longer times to resolution. Men with uncomplicated UTIs should be treated as above but for 7 to 14 days.

Comment

These recommendations are consistent with those of other expert guidelines. The antibiotic recommendations often are violated (particularly regarding inappropriate use of fluoroquinolones), but in real-world practices, we often find adherence difficult, especially in middle-aged and older patients. For example, many patients have sulfa allergies or take medications that can increase sulfa toxicity (NEJM JW Gen Med Nov 7 2014), and nitrofurantoin is contraindicated in patients with glomerular filtration rates <60 mL/minute/1.73 m2.

Editor Disclosures at Time of Publication

Disclosures for Thomas L. Schwenk, MD at time of publication Editorial boards UpToDate

Citation(s):

    Grigoryan L et al. Diagnosis and management of urinary tract infections in the outpatient settings: A review. JAMA 2014 Oct 22/29; 312:1677. (Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος)

    PubMed abstract (Free)

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