The American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine have endorsed the 2010 IDSA-ESCMID guidelines. The IDSA and ESCMID plan to evaluate the need for revisions to the 2010 guidelines based on an annual review of the current literature.
The 2010 IDSA-ESCMID guidelines are a resource available to hospitalists treating acute uncomplicated cystitis and pyelonephritis. As important differences exist between the target population and the hospitalist’s patient population, there are some key points to consider for clinicians treating cystitis or pyelonephritis in hospitalized patients.
Importantly, while nitrofurantoin is favored as a first-line antimicrobial agent for cystitis in the 2010 IDSA-ESCMID guidelines, it might be problematic in hospitalized patients for several reasons:
- it is not approved or recommended for the treatment of pyelonephritis;
- it is contraindicated in patients with creatinine clearance <60 ml/min; and
- it is generally not recommended for use in patients >65 years old because of the risk of renal impairment (Beers Criteria).5
Additionally, the treatment of acute cystitis in men requires special consideration. Notably, nitrofurantoin is not recommended in men because of poor prostatic tissue penetration, and although studies are limited, some sources recommend a longer treatment duration of at least 7 days.6 Finally, hospitalized patients commonly have other conditions, such as urological abnormalities, indwelling Foley catheters, recent urinary tract instrumentation, recent use of antibiotics, risk for multi-drug resistant organisms, potential interactions with other medications, and immunosuppression. The presence of any of these factors will influence the choice of empiric therapy and may warrant treatment for complicated cystitis or pyelonephritis, which are not addressed by these guidelines.
Drs. Tarvin and Sponsler are academic hospitalists at Vanderbilt University School of Medicine in Nashville, Tenn.
- Huang ES, Stafford RS. National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Arch Intern Med. 2006;166:635-639.
- Kahan NR, Chinitz DP, Kahan E. Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money. J Clin Pharm Therap. 2004;29:59-63.
- Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Inf Dis. 2011;52(5):e103-20.
- Warren JW, Abrutyn E, Hebel JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America. Clin Inf Dis. 1999;29(4):745-58.
- Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a U.S. consensus panel of experts. Arch Intern Med. 2003;163(22):2716-2724.
- Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. A Fam Phys. 2005;72(3):451-456.