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Pyelonephritis (Acute): Antimicrobial Prescribing Guideline Evidence Review

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Pyelonephritis (Acute): Antimicrobial Prescribing Guideline Evidence Review National Institute for Health and Care Excellence Final Pyelonephritis (acute): antimicrobial prescribing guideline Evidence review NICE guideline 111 October 2018 Contents Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties. NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn. Copyright © NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3124-8 Contents Contents Contents .............................................................................................................................. 4 1 Context .......................................................................................................................... 6 1.1 Background ........................................................................................................... 6 1.2 Managing infections that require antibiotics ........................................................... 7 1.2.1 Self-care .................................................................................................... 7 1.2.2 Antibiotic prescribing strategies .................................................................. 8 1.3 Safety netting advice ............................................................................................. 8 1.4 Symptoms and signs of a more serious illness or condition (red flags) .................. 9 2 Evidence selection ..................................................................................................... 10 2.1 Literature search ................................................................................................. 10 2.2 Summary of included studies............................................................................... 10 3 Clinical effectiveness ................................................................................................. 14 3.1 Non-pharmacological interventions ..................................................................... 14 3.2 Non-antimicrobial pharmacological interventions ................................................. 14 3.3 Antimicrobials in adults ........................................................................................ 14 3.3.1 Back-up antibiotics ................................................................................... 14 3.3.2 Antibiotics compared with placebo ........................................................... 14 3.3.3 Choice of antibiotic ................................................................................... 14 3.3.4 Antibiotic dosing and course length .......................................................... 18 3.3.5 Route of antibiotic administration ............................................................. 19 3.4 Antimicrobials in children ..................................................................................... 21 3.4.1 Back-up antibiotics ................................................................................... 21 3.4.2 Antibiotics compared with placebo ........................................................... 21 3.4.3 Choice of antibiotic ................................................................................... 22 3.4.4 Frequency of antibiotic dosing .................................................................. 22 3.4.5 Antibiotic course length ............................................................................ 23 3.4.6 Route of antibiotic administration ............................................................. 23 4 Safety and tolerability ................................................................................................ 26 4.1 Non-pharmacological interventions ..................................................................... 26 4.2 Non-antimicrobial pharmacological interventions ................................................. 26 4.3 Antimicrobials ...................................................................................................... 26 4.3.1 Antibiotics in adults .................................................................................. 27 4.3.2 Antibiotics in children ............................................................................... 28 5 Antimicrobial resistance ............................................................................................ 30 6 Other considerations ................................................................................................. 33 6.1 Resource impact ................................................................................................. 33 6.1.1 Antibiotics ................................................................................................ 33 6.2 Medicines adherence .......................................................................................... 33 7 Terms used in the guideline ...................................................................................... 34 4 Contents Acute pyelonephritis in the included studies ........................................................ 34 Complicated urinary tract infection in the included studies ................................... 34 Pyrexia 34 Sepsis 34 Sequential antibiotic ............................................................................................ 34 Vesicoureteral reflux ............................................................................................ 35 Appendices ........................................................................................................................ 36 Appendix A: Evidence sources .................................................................................. 36 Appendix B: Review protocol ..................................................................................... 39 Appendix C: Literature search strategy ..................................................................... 46 Appendix D: Study flow diagram ................................................................................ 58 Appendix E: Evidence prioritisation .......................................................................... 59 Appendix F: Included studies .................................................................................... 60 Appendix G: Quality assessment of included studies .............................................. 62 G.1 Antimicrobials ............................................................................................................ 62 Appendix H: GRADE profiles ...................................................................................... 65 H.1 Antimicrobials for acute pyelonephritis and complicated urinary tract infection in adults ...................................................................................................................... 65 H.2 Antimicrobials for acute pyelonephritis in children ................................................. 86 Appendix I: Studies not-prioritised ........................................................................... 97 Appendix J: Excluded studies ................................................................................... 98 5 Context 1 Context 1.1 Background Urinary tract infection (UTI) is a non‑specific term that refers to infection anywhere in the urinary tract (Frassetto 2015). This evidence review covers acute pyelonephritis and complicated urinary tract infection. Uncomplicated lower UTI, recurrent UTI and catheter-associated UTI are covered in separate evidence reviews. Pyelonephritis is an infection of the kidneys. Acute pyelonephritis may be caused by bacteria moving from the lower urinary tract or spreading via the bloodstream to the kidney. Most episodes of pyelonephritis are uncomplicated and result in no residual kidney damage. Complicated infections can result from underlying medical problems, genitourinary anatomical abnormalities, obstruction or multi-drug resistant pathogens (Frassetto 2015). Common signs and symptoms of pyelonephritis include acute-onset fever, chills, severe back or flank pain, nausea and vomiting, and costovertebral angle tenderness. The clinical knowledge summary (CKS) on pyelonephritis states that there are no clinical features or routine investigations that conclusively distinguish acute
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