The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients. Part II: Therapy and Prevention

Abstract

Background: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Results are published in 2 parts. Part 1 covers methods, the definition of patient groups, and diagnostics. This second publication focuses on treatment of acute episodes of cystitis and pyelonephritis as well as on prophylaxis of recurrent UTIs. Materials and Methods: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, EMBASE, and the Cochrane Library to identify literature published in 2010–2015. Results: For the treatment of acute uncomplicated cystitis (AUC), fosfomycin-trometamol, nitrofurantoin, nitroxoline, pivmecillinam, and trimethoprim (depending on the local rate of resistance) are all equally recommended. Cotrimoxazole, fluoroquinolones, and cephalosporins are not recommended as antibiotics of first choice, for concern of an unfavorable impact on the microbiome. Mild to moderate uncomplicated pyelonephritis should be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For AUC with mild to moderate symptoms, instead of antibiotics symptomatic treatment alone may be considered depending on patient preference after discussing adverse events and outcomes. Primarily non-antibiotic options are recommended for prophylaxis of recurrent urinary tract infection. Conclusion: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

Changes in Antimicrobial Resistance of Urinary Tract Infections in Adult Patients over a 5-Year Period

“…Treatment guidelines present options extending from behavioral changes to antimicrobial therapy in the treatment of UTI. Local resistance rates must be considered in the selection of empirical treatment [6,8,9]. In our study, most of the patients whose urine culture has yielded bacterial growth were > 60 years of age, and 64% were women.…”

Non-Antibiotic Herbal Therapy (BNO 1045) versus Antibiotic Therapy (Fosfomycin Trometamol) for the Treatment of Acute Lower Uncomplicated Urinary Tract Infections in Women: A Double-Blind, Parallel-Group, Randomized, Multicentre, Non-Inferiority Phase III Trial

“…Previous studies have suggested that overall AB use could be greatly reduced by initial symptomatic treatment of lower uUTIs with NSAIDs [9,10], even though symptomatic treatment with these agents is clinically inferior to ABs. Nevertheless, these results were compelling enough for the German Clinical Guidelines [22] to encourage the use of non-AB symptomatic treatment in cases of acute lower uUTIs with mild-to-moderate symptoms.…”

Evaluation of the draft guidelines proposed by EMA and FDA for the clinical diagnosis of acute uncomplicated cystitis in women

“…Urinary tract infections (UTIs) are among the most widespread infectious diseases in general practice [17], with 80% of cases classified as uUTIs. Although current guidelines recommend antibiotics as the first choice of treatment for the acute phase [2,18], several prospective randomized, placebo-controlled studies comparing antibiotic and nonantimicrobial symptomatic therapeutic modalities have been performed [19][20][21][22]. Results of these studies were compelling enough for the updated German Clinical Guidelines [18] to encourage the use of the non-AB symptomatic treatment in selected cases of acute lower uUTIs with mild-to-moderate symptoms.…”