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Review
October 22/29, 2014

Diagnosis and Management of Urinary Tract Infections in the Outpatient SettingA Review

Author Affiliations
  • 1Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
  • 2Houston VA Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
  • 3Section of Infectious Diseases, Department of Medicine and Department of Surgery, Baylor College of Medicine, Houston, Texas
  • 4Section of Infectious Diseases, Department of Medicine, Boston Veterans Affairs Healthcare System and Boston University School of Medicine, Boston, Massachusetts
JAMA. 2014;312(16):1677-1684. doi:10.1001/jama.2014.12842
Abstract

Importance  Urinary tract infection is among the most common reasons for an outpatient visit and antibiotic use in adult populations. The increasing prevalence of antibacterial resistance among community uropathogens affects the diagnosis and management of this clinical syndrome.

Objectives  To define the optimal approach for treating acute cystitis in young healthy women and in women with diabetes and men and to define the optimal approach for diagnosing acute cystitis in the outpatient setting.

Evidence Review  Evidence for optimal treatment regimens was obtained by searching PubMed and the Cochrane database for English-language studies published up to July 21, 2014.

Findings  Twenty-seven randomized clinical trials (6463 patients), 6 systematic reviews, and 11 observational studies (252 934 patients) were included in our review. Acute uncomplicated cystitis in women can be diagnosed without an office visit or urine culture. Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5-7 days), and fosfomycin trometamol (3 g in a single dose) are all appropriate first-line therapies for uncomplicated cystitis. Fluoroquinolones are effective for clinical outcomes but should be reserved for more invasive infections. β-Lactam agents (amoxicillin-clavulanate and cefpodoxime-proxetil) are not as effective as empirical first-line therapies. Immediate antimicrobial therapy is recommended rather than delayed treatment or symptom management with ibuprofen alone. Limited observational studies support 7 to 14 days of therapy for acute urinary tract infection in men. Based on 1 observational study and our expert opinion, women with diabetes without voiding abnormalities presenting with acute cystitis should be treated similarly to women without diabetes.

Conclusions and Relevance  Immediate antimicrobial therapy with trimethoprim-sulfamethoxazole, nitrofurantoin, or fosfomycin is indicated for acute cystitis in adult women. Increasing resistance rates among uropathogens have complicated treatment of acute cystitis. Individualized assessment of risk factors for resistance and regimen tolerability is needed to choose the optimum empirical regimen.

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