WikiGuidelines group publishes first new UTI guidance in 14 years
Click Here to Manage Email Alerts
Key takeaways:
- WikiGuidelines provided clear recommendations on six of 37 UTI-related questions it posed to the collaborative.
- The guidelines are the first for UTI prevention, diagnosis and management in more than a decade.
The WikiGuidelines collaborative has published its third clinical practice guidance — this one on the prevention, diagnosis and management of UTIs.
A large group of researchers from 12 countries reviewed more than 900 articles and came away with clear recommendations for six of 37 questions about UTI care, and partial recommendations for another three.
According to Zack Nelson, PharmD, MPH, a clinical pharmacy specialist in infectious diseases at Park Nicollet Health Services in St. Louis Park, Minnesota, one major change was the suggestion by the group that the terms “uncomplicated” and “complicated” be abandoned, which contrasts with existing guidelines.
WikiGuidelines has previously published guidance on infective endocarditis and pyogenic osteomyelitis. The group’s stated goal is to “create guidelines which standardize clinical care with the humility of uncertainty.”
For the UTI guidance, Nelson and 53 other members of the collaborative reviewed 914 studies to provide information on five areas of UTI care: prophylaxis and prevention; diagnosis and diagnostic stewardship; empirical treatment; definitive treatment and antimicrobial stewardship; and special populations and genitourinary syndromes.
We asked Nelson if the new guidance clashes with established practice.
“Whether they clash with existing recommendations is a loaded question,” Nelson said. “I think the big emphasis is on the fact that this is the first UTI guideline in over 14 years.”
Six recommendations
Based on its review, the group was able to put together recommendations for six questions. Below are the questions as worded by the WikiGuidelines authors, and an excerpt or summary of each guideline sent by Nelson to Healio.
Q: Is there a role for cranberry juice or supplements in the prevention of UTIs?
Nelson: Cranberry juice or supplements reduce the risk of symptomatic, culture-verified UTIs in women and children. However, evidence for their use in older adults, those with bladder emptying problems or pregnant women is insufficient to make a clear recommendation for or against its use.
Q: Is there a role for topical estrogen in the prevention of UTIs?
Nelson: Based on available evidence from 30 randomized clinical trials and one large retrospective observational study, topical estrogen is effective at reducing recurrent UTIs in postmenopausal women.
Q: Is there a role for methenamine hippurate in the prevention of UTIs?
Nelson: A systematic review, which included a multicenter, open-label, randomized noninferiority trial conducted in the United Kingdom from June 2016 to June 2018, compared the efficacy of methenamine with daily low-dose antibiotics in preventing recurrent UTIs in women aged 18 years and older and found that methenamine was noninferior to antibiotics for the prevention of UTIs.
Q: What are reasonable empirical treatment regimen(s) for pediatric or adult patients diagnosed with a UTI?
Nelson: Empirical treatment regimens for pediatric and adult patients should contain antimicrobials that historically demonstrated efficacy and safety in the treatment of UTIs, achieve adequate urinary concentrations and provide reliable activity against the most common pathogens based on local resistance rates.
Q: What are optimal oral agents and an appropriate duration of treatment for gram-negative bacteremia from a urinary source?
Nelson: Multiple randomized clinical trials composed of patients with gram-negative bacteremia from predominantly urinary sources demonstrate noninferiority of 7 days compared with 14 days of treatment for a variety of patient-oriented outcomes, including clinical cure, clinical failure, relapse and all-cause mortality.
Q: What is the optimal clinical approach for patients with nephrolithiasis, foreign objects, nephrostomy tubes and/or ureteral stents?
Nelson: Routine cystoscopy and urodynamic studies do not require antimicrobial prophylaxis in asymptomatic patients. Preoperative antibiotics do not appear to reduce infectious complications from routine cystoscopic stent removal or nephrostomy tube placement.
In most patients with uncomplicated urologic cases undergoing percutaneous nephrolithotomy, a single dose of antimicrobial prophylaxis appears to reduce the risk of infection.
Three partial recommendations
In addition to the guidance above, Nelson and colleagues formulated partial recommendations for adult cystitis and pyelonephritis and some recommendations for UTI stewardship strategies.
Below are the three questions that resulted in partial guidance, and a summary of what the authors wrote.
Q: What is the appropriate duration of treatment for acute cystitis in adults?
The collaborative made recommendations for the optimal treatment duration for cystitis, regardless of biological sex, for six antimicrobial classes, all ranging between 3 to 5 days — except for oral fosfomycin, which is given as one dose. The researchers found insufficient data to make recommendations on other classes, including beta lactams and parenteral aminoglycosides.
Q: What is the appropriate duration of treatment for acute pyelonephritis and/or febrile UTI in adults?
Although duration recommendations were made by the collaborate for fluoroquinolones (5 to 7 days) and dose-optimized beta lactams (7 days), it found insufficient evidence to make recommendations for several other antimicrobials, or to provide a clear recommendation on how long to treat febrile UTIs.
Q: What are effective antimicrobial stewardship strategies that can optimize the rational and sustainable use of antimicrobials in the setting of treatment of UTIs?
The collaborative was able to make specific recommendations that encouraged de-escalation and using mostly or all oral treatment, which can reduce hospital stays and lower the risk for adverse events linked to IV antibiotic treatment, according to the guideline.
References:
- Nelson Z, et al. JAMA Network Open. 2024;doi:10.1001/jamanetworkopen.2024.44495.
- WikiGuidelines. https://wikiguidelines.org/. Accessed Nov. 11, 2024.
Collapse
Read more about
Click Here to Manage Email Alerts