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February 2011
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Updated IDSA/ESCMID Guideline for Uncomplicated Cystitis

An updated guideline for the treatment of acute uncomplicated cystitis and pyelonephritis in women is now available online. Developed by IDSA and the European Society for Clinical Microbiology and Infectious Diseases (ESCMID), and previously updated in 1999, the guideline appears in the March 1 issue of Clinical Infectious Diseases.

The guideline reflects several changes since 1999 affecting management of  these infections, such as an increase in antimicrobial resistance among uropathogens, an appreciation of the ecological adverse effects of antimicrobial therapy (collateral damage), and a focus on clinical outcomes.

Recommendations give clinicians direction regarding the optimal treatment in adult non-pregnant, premenopausal women. Specifically, the guideline presents doses and durations of different treatment regimens in the context of changing resistance rates. In addition, better estimations of response rates for women resistant to drug treatment are discussed.

The 2010 guideline also has an international focus and incorporates drugs that are not uniformly available or familiar to U.S.-based clinicians, such as pivmecillinam and fosfomycin. The main message of the guideline is that no single agent is the optimal choice for management of uncomplicated urinary tract infections, and local resistance patterns, drug availability, expected efficacy, and individual patient characteristics all need to be taken into consideration on a case by case basis.

“The treatment algorithm is less of a cookbook approach and more of a decision-making process that hopefully will be incorporated into everyday practice,” said Kalpana Gupta, MD, lead author of the guideline and chief of the Section of Infectious Diseases at VA Boston Health Care System. “No single drug will be the right answer for every patient every time.”

The guideline notes several areas of research regarding the treatment of uncomplicated cystitis that will require further investigation.  Future updates should address a better understanding of collateral damage from short course cystitis regimens, the public health impact of antimicrobial use and resistance in women, and the efficacy of short course (7-10 day) regimens with trimethoprim-sulfamethoxazole for pyelonephritis.

Several key performance measures identified in the guideline include: 

  • use of a recommended antimicrobial for treatment of uncomplicated cystitis in cases where it is not prohibited due to allergy history or availability
  • use of fluoroquinolones for treatment of acute uncomplicated cystitis only when a recommended antimicrobial cannot be used
  • use of a recommended antimicrobial for treatment of uncomplicated pyelonephritis in cases where it is not prohibited due to allergy history or availability
  • initiation of empiric therapy for acute uncomplicated pyelonephritis with performance of a pre-therapy urine culture and modification of empiric therapy as indicated by culture results

Available online, this guideline is dedicated to the memory of Walter E. Stamm, MD, FIDSA, whose work and commitment over several decades enhanced the understanding of the pathogenesis, epidemiology, and management of urinary tract infections in women.

Other IDSA guidelines are available on the Standards, Practice Guidelines, and Statements page of our website.
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