Dossier n. 190/2010 [Abstract] Urinary tract infections in adults. Regional guideline

Background

Urinary tract infections (UTIs) are a common problem in adults which frequently cause prescriptions of laboratory tests and use of antibiotics. Prescriptions for UTIs have a significant impact on total antibiotic consumption and are associated both with an expenses increase for healthcare and with the spread of antibiotic resistance. This phenomenon shows a significant increase among uropathogens and it is enhanced by the - often inappropriate - use of broad spectrum agents like fluoroquinolones that are more and more prescribed in the community and hospitals. Therefore, based on regional data of antibiotic prescription and resistance of the most common uropathogens, the Regional Healthcare and Social Agency is involved in improving UTI management in adults.

General objective

To reduce the excessive and inappropriate use of antibiotics in adults through the development of a widely accepted guideline aimed at improving the management of lower UTIs.

Specific objectives

The guideline focuses on the management (prevention, diagnosis, treatment and follow up) of:

• uncomplicated UTIs (asymptomatic bacteriuria, acute cystitis, recurrent cystitis);
• lower UTIs in pregnant women;
• complicated lower UTIs (infections in males and in patients with indwelling urinary catheter).

The guideline does not include recommendations for pyelonephritis management.

Method

A regional multidisciplinary working group was created to develop an evidence based guideline for UTI management and to identify the possible implementation plans and monitoring activities to be conducted in collaboration with Local Health Authorities.

In the first part of the guideline a summary of the recommendations is available for prompt consultation. The core part of the document consists of the presentation of regional data and the discussion of evidences used to develop the recommendations.

The working group adopted a modified version of the international GRADE system. The grading scheme classifies recommendations as strong or weak according to the quality of evidence, the clinical importance of the outcomes considered, the balance among benefits, risks and costs, and the feasibility of the recommendation. The reasons that determined the attribution of the grade to every single recommendation are also reported.

The document presents some implementation experiences of UTI management published in literature.

Finally, relevant information for women suffering from recurrent UTI and for people with urinary catheter and their relatives is reported. Evidence table and literature search strategies are also provided.

The guideline can be downloaded from the website of the Regional Healthcare and Social Agency in two formats:

• full guideline;
• quick reference guide.

The publication of leaflets for patients has also been planned.

Key messages

• The diagnosis of UTI is a clinical diagnosis: it is primarily based on symptoms and signs and should not rely exclusively on laboratory tests that detect the presence of bacterial and white cells in urine.
• Routine urine culture is not required to manage uncomplicated UTI.
• There is a risk of false positive results with all tests for diagnosis of bacteriuria used at hospital and at community level. The only reliable test is the culture of urine obtained by needle aspiration of the bladder, that it is not routinely performed in Emilia-Romagna.
• Bacteriuria is not a disease.
• Asymptomatic bacteriuria should be diagnosed and treated only in pregnant women and before a surgery involving the urinary tract.
• Fluorquinolones should not be used for treating uncomplicated UTI. They should be used only when other options are not available, because the rate of uropathogens resistance against fluorquinolones is increasing.
• Indwelling catheters should be placed only when no other options are available. Catheter should be removed as soon as it is no longer required.
• Routine prophylactic antimicrobials should not be administered to patients at the time of catheter replacement: they do not reduce the risk of catheter-associated UTI while they increase the risk of developing antimicrobial resistance.
• Routine urine culture or other urinary tests should not be performed in patients with urinary catheter.