Managing complicated urinary tract infections is difficult, and new guidelines from IDSA can help clinicians improve patient care and reduce unnecessary antibiotic use. Several authors of the guidelines answer questions from Science Speaks about the new recommendations, highlighting key updates, a new classification for what constitutes a complicated UTI and the impact of rising rates of antibiotic resistance on treatment selection.
Who are these updated guidelines primarily intended for? Who will find them most useful?
We wrote these guidelines for clinicians who evaluate and treat patients with complicated UTI, typically in the emergency department, urgent care clinics and hospital wards. Specifically, these guidelines target hospitalists, primary care clinicians, emergency room clinicians, infectious diseases specialists and pharmacists. Our panelists represent these diverse medical specialties, and their perspectives kept our recommendations grounded in what would be most relevant to front-line clinicians.
What are the key updates or changes compared to previous guidelines for UTI?
We focused these guidelines on cUTI treatment because this infection is common, and IDSA has not previously published clinical practice guidelines for cUTI. The 2010 IDSA UTI guidelines were limited to healthy premenopausal women with acute uncomplicated cystitis and pyelonephritis, leaving clinicians without guidance on how to manage men with UTI or sicker patients requiring hospitalization for UTI.
In order to write guidelines about cUTI, we first had to agree on what “complicated UTI” means. That led us to develop updated consensus definitions of uncomplicated versus complicated UTI (see below). We then focused on three essential clinical questions:
- How do we best select empiric antibiotics for cUTI?
- When can we switch antibiotics for cUTI from the parenteral to oral route?
- How long should most cUTIs be treated?
We have more work left to do! We have a fourth clinical question in progress, about the role of imaging in evaluating patients presenting with suspected cUTI. Other future work includes updating the uncomplicated UTI guidelines and developing UTI diagnostic guidelines.
How do the guidelines clarify the difference between uncomplicated and complicated UTI?
Our understanding of what constitutes uncomplicated and complicated urinary tract infection has evolved since IDSA’s 2010 UTI guidelines (figure). Clinical practice considerations drove these changes — the goal was a clear definition of cUTI that would help clinicians accurately identify patients with more serious infections using readily available information (e.g., vital signs, symptoms of pyelonephritis and the presence of a urinary catheter). Our new classification of UTI focuses on whether or not the infection is likely to be confined to the bladder; if so, the infection is defined as an uncomplicated UTI. Systemic signs of illness, such as fever or bacteremia, as well as catheter-related infection and clinical signs of pyelonephritis, suggest that the infection has extended beyond the bladder and is thus defined as a complicated UTI.
In contrast to prior definitions, patients who have underlying urologic abnormalities, have diabetes or who are immunocompromised are no longer automatically classified as having a complicated UTI. By this classification, both men and women can have uncomplicated UTI, though importantly, choice of antibiotics and duration of treatment for uncomplicated UTI may differ for men and women.
How have increasing rates of antibiotic resistance affected the recommendations?
Bacteria causing UTIs collected from clinics and ERs across the United States now have antimicrobial resistance rates above the thresholds recommended for empiric treatment in the 2010 UTI guidelines. In the face of these growing rates of resistance, we had to reevaluate the evidence for guiding empiric choice of antibiotics for cUTI.
The bottom line of our findings is that because antibiotic resistance is common and increasing, but also varies greatly between hospitals and between patients, there is no one best drug to empirically treat cUTI. Instead of recommending specific antibiotics, we propose a four-step process that clinicians can apply to each patient with cUTI, at the point of care, to guide the initial empiric antibiotic choice. In recommending a decision process rather than a single drug of choice, our hope is that the usefulness of this guideline will endure as antibiotic resistance continues to escalate and new antibiotics are developed.
To optimize the selection of empiric antibiotics for patients with suspected cUTI, we recommend clinicians follow these four steps (figure):
- Assess the severity of illness (to determine the risk/benefit of narrower spectrum antibiotic selection).
- Consider patient-specific risk factors for resistant uropathogens (e.g., avoiding antibiotics to which the patient has recently had a UTI with a resistant bacteria).
- Evaluate other patient-specific considerations (focusing on minimizing risk of adverse events).
- For patients with sepsis, consult a relevant local antibiogram if available (to further improve the likelihood of giving appropriate empiric therapy in patients with the least margin for error).
What else should clinicians know about this update?
Our guidelines also address duration of treatment for cUTI, typically seven days, and the timing of the IV to oral antibiotic switch (as soon as the patient is improving clinically) (figure).
These are treatment guidelines for cUTI — we do not address diagnosis, and we do not address uncomplicated UTI. We hope to have the opportunity to cover these topics in future IDSA guidelines updates. Please take a look at the full text of the guidelines: Yes, they are lengthy, but you will find explanations and information relevant to your clinical practice.
To learn more, see the full guidelines, “Complicated Urinary Tract Infections (cUTI): Clinical Guidelines for Treatment and Management.”