ISSN 2465-8243(Print) / ISSN: 2465-8510(Online) https://doi.org/10.14777/uti.2017.12.2.55 Review Urogenit Tract Infect 2017;12(2):55-64 http://crossmark.crossref.org/dialog/?doi=10.14777/uti.2017.12.2.55&domain=pdf&date_stamp=2017-08-25 The Clinical Guidelines for Acute Uncomplicated Cystitis and Acute Uncomplicated Pyelonephritis Ki Ho Kim, Jae Heon Kim1, Seung-Ju Lee2, Hong Chung3, Jae Min Chung4, Jae Hung Jung5, Hyun Sop Choe2, Hun Choi6, Sun-Ju Lee7; The Committee of The Korean Association of Urogenital Track Infection and Inflammation Department of Urology, Dongguk University College of Medicine, Gyeongju, 1Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, 2Department of Urology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, 3Department of Urology, Konkuk University Chungju Hospital, Konkuk University School of Medicine, Chungju, 4Department of Urology, Pusan National University Yangsan Hospital, Yangsan, 5Department of Urology, Yonsei University Wonju College of Medicine, Wonju, 6Department of Urology, Korea University Ansan Hospital, Ansan,7Department of Urology, Kyung Hee University School of Medicine, Seoul, Korea To date, there has not been an establishment of guidelines for urinary tract Received: 10 April, 2017 infections, due to limited domestic data in Korea, unlike other North American and Revised: 25 April, 2017 Accepted: 25 April, 2017 European countries. The clinical characteristics, etiology, and antimicrobial susceptibility of urinary tract infections vary from country to country. Moreover, despite the same disease, antibiotic necessary to treat it may vary from country to country. Therefore, it is necessary to establish a guideline that is relevant to a specific country. However, in Korea, domestic data have been limited, and thus, guidelines considering the epidemiological characteristics pertaining specifically to Korea do Correspondence to: Ki Ho Kim not exist. Herein, describe a guideline that was developed by the committee of The http://orcid.org/0000-0001-8532-6517 Korean Association of Urogenital Tract Infection and Inflammation, which covers Department of Urology, Dongguk University College of Medicine, 87 Dongdae-ro, Gyeongju 38067, Korea only the uncomplicated urinary tract infections, as covering all parts in the first Tel: +82-54-770-8525, Fax: +82-54-770-8503 production is difficult. E-mail: [email protected] Keywords: Cystitis; Pyelonephritis; Urinary tract infections; Guideline This guideline is a reference for all patients; it may not be uniformly applicable to all patients. The clinical judgment should be made on a case-by-case Copyright 2017, Korean Association of Urogenital Tract Infection and Inflammation. All rights reserved. basis. This is an open access article distributed under the terms of the Creative Commons Attribution This guideline can be used for personal medical and Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits educational purposes, but it cannot be used for unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is commercial purposes or medical examination properly cited. purposes. INTRODUCTION from the most recently published Asian Association of UTI & STI (2016), Asian European Association of Urology (2014), 1. Background and Purpose Infectious Diseases Society of America (2011), and AMMI Urinary tract infections (UTIs) are one of the most Canada Guidelines Committee (2005). Major literature common infectious diseases. They are divided according published in Korea was searched using MEDLINE (January to the site of infection, presence or absence of symptoms, 1976 to September 2014), Embase (January 1985 to anatomical or functional abnormalities, and the presence September 2014), Cochrane Library (January 1987 to or absence of underlying diseases. The aim of this study September 2014), and KoreaMed (January 1958 to September was to develop a guideline for uncomplicated UTIs. 2014). We used the following keywords to search these databases: “cystitis,” “pyelonephritis,” “urinary tract 2. Methodology infections,” “necrotizing pyelonephritis,” “pyelonephritides,” The guideline presented here is based on the guidelines “Korea.” 55 56 Ki Ho Kim, et al. Clinical Guideline for Uncomplicated UTIs 3. Level of Evidence and Grade of the 1) Definition Recommendation Acute cystitis is a symptom characterized by lower urinary The level of evidence (LE) and the grade (GR) of tract symptoms, such as discomfort in the pubic area, as recommendation were accepted and used in accordance well as storage symptoms, such as pain during urination with the recent guidelines of the Oxford Center for without vaginal discharge, urinary frequency, urgency, and Evidence-Based Medicine. nocturia (LE: 2a, GR: B). There must be no risk factors that can cause complicated UTIs. 1) Level of evidence I: Evidence from at least one randomized controlled trial 2) Diagnosis II: Evidence obtained from at least one well-designed Urine dipstick test and urinary microscopy are widely controlled study without randomization used basic diagnostic methods [1]. Although urinalysis is III: Evidence obtained from well-designed non-experi- not mandatory, it is advised to perform a culture test, if mental studies, such as comparative studies, correla- acute pyelonephritis suspicion persists for 2-4 weeks or tion studies, and case reports there is recurrent cystitis symptoms (LE: 4, GR: B). In Korea, IV: Evidence obtained from expert committee reports, UTIs have a high rate of resistance to antibiotics. Acute opinions, or clinical experience of respected authorities cystitis is diagnosed when the urine (microscopy, more than 10 leukocytes) is observed or the colony is more than 2) Grade of recommendation 10,000 cfu/ml [2,3]. Additional diagnostic studies should A: Good evidence to support the recommendation for be considered when there is atypical symptoms, fever or against use without costovertebral angle tenderness, or no response B: Moderate evidence to support the recommendation to treatment (LE: 4, GR: B) [4,5]. for or against use C: Poor evidence to support the recommendation 3) Treatment Antibiotic treatment is recommended for patients with CLINICAL PRACTICE GUIDELINES BY acute cystitis because antibiotics have a significant DISEASE therapeutic benefit compared with placebos [6]. Since the resistance rate of E. coli to fluoroquinolone has already 1. Acute Uncomplicated Cystitis been reported to be greater than 20% in Korea, Acute uncomplicated cystitis is the most common UTI fluoroquinolone should be used carefully to empirically occurring mainly in adult women, especially sexually active treat simple UTIs [7,8]. Therefore, in the selection of young women and postmenopausal women. It is the most empirical antibiotics, it is important to consider the risk frequently encountered disease in primary medical factors of antibiotic resistance in patients, as well as the institutions, including urology, obstetrics, and gynecology. tendency to susceptibility of the area. Moreover, antibiotics More than half of healthy adult women visit the hospital should be altered in accordance with clinical features, and with acute uncomplicated cystitis at least once in their the duration of treatment should be adjusted in accordance lifetime. Escherichia coli is the most common organism with clinical features and persistence of symptoms. responsible for acute uncomplicated cystitis, followed by The criteria for determining empirical antibiotics are as Staphylococcus saprophyticus, Klebsiella pneumoniae, and follows: Proteus mirabilis. trimethoprim-sulfamethoxazole (TMP-SMX) • Clinical examination (no clinical symptoms of or fluoroquinolone was used as an empirical antibiotic. pyelonephritis such as high fever and flank pain, the However, fluoroquinolone-resistant strains and extended history of complicated UTIs such as diabetes) spectrum beta-lactamase (ESBL)-bacteria have increased, • Spectrum and susceptibility pattern of pathogenic requiring regional antibiotic resistance information and bacteria antibiotic guidelines. • Therapeutic patterns and antibiotic resistance rates in the community Urogenit Tract Infect Vol. 12, No. 2, August 2017 Ki Ho Kim, et al. Clinical Guideline for Uncomplicated UTIs 57 • Availability, tolerability, history of hypersensitivity to clavulanate 500 mg/125 mg oral twice a day, cefaclor 250 drugs, and side effects mg oral three times a day, cefdinir 100 mg oral three times • Cost a day, cefcapene pivoxil 100 mg oral three times a day, • Compliance to treatment and cefpodoxime proxetil 100 mg oral twice a day is A 3-day fluoroquinolone therapy has been widely used recommended (LE: 1, GR: A). and recommended as an empirical antibiotic treatment for In regions where the resistance rate of E. coli to TMP-SMX acute cystitis (LE: 1, GR: A). Ciprofloxacin 500 mg oral is less than 20%, it is possible to administer TMP-SMX bid (twice a day) for 3 days, ciprofloxacin SR 500 mg qd 160/800 mg twice daily for 5 days [12-14] (LE: 1b, GR: (once a day) for 3 days, and tosufloxacin 150 mg oral B). However, according to a recent multicenter antibiotic bid are recommended [9] (LE: 1b, GR: B). In Korea, resistance study for UTIs, 30% or more of E. coli identified fluoroquinolone is not approved to treat acute cystitis, which in patients with acute uncomplicated cystitis is resistant can lead to insurance-related problems. Due to