DOI: https://doi.org/10.18370/2309-4117.2019.48.43-48

Review of current clinical guidelines for the diagnosis and treatment of urinary tract infections in women

О. А. Бурка, Т. М. Тутченко, А. В. Шумицький

Abstract


Recurrent urinary tract infections in women is a challenging issue for many specialists including gynecologists. The article provides an overview of current (2018–19) evidence based recommendations on causes, risk factors and algorithms for diagnosing urinary tract infections in women, as well as current views on asymptomatic bacteriuria. New clinical guidelines focus on the need to pay greater attention to the problem of antibiotic resistance, which continues to grow primarily due to the excessive and often unsystematic use of antibacterial drugs.

The most common pathogen of acute and recurrent uncomplicated cystitis is Escherichia coli, less common Staphylococcus saprophyticus, Klebsiella pneumoniae, Proteus mirabilis. The most common cause of urethritis in women of reproductive age is sexually transmitted infections: Neisseria gonorrhea, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma spр.., Ureaplasma spp. In postmenopausal women non-communicable causes predominate.

According to the American Urological Association, the Canadian Urological Association, the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction recommendations from 2019 all women with clinical manifestations of urethritis/cystitis should undergo gynecological examination and comprehensive laboratory examination.

The main signs of urinary tract infection in general urine analysis are pyuria; presence of nitrites; minor or moderate proteinuria; changes in physical properties, presence of erythrocytes (nonspecific signs). Of great importance for the effective treatment of recurrent urinary tract infections is urine culture with definitions of the sensitivity of the pathogens to antibiotics. The effectiveness of urine culture tests depends on the accuracy of biomaterial collection and the conditions for its storage/transportation at the preanalytical stage. Because of the similarity of clinical manifestations of cystitis with urethritis, the cause of which in most cases is sexually transmitted infections, all women need undergo comprehensive clinical and laboratory examination, including gynecological examination and modern diagnosis of sexually transmitted infections.


Keywords


cystitis; urethritis; antibiotic resistance; urine culture; Escherichia coli; sexually transmitted infections

References


Geerlings, S.E. «Clinical Presentations and Epidemiology of Urinary Tract Infections.» Microbiol Spectr 4 (2016). DOI: 10.1128/microbiolspec.UTI-0002-2012

Gupta, K., Trautner, B.W. «Diagnosis and management of recurrent urinary tract infections in non-pregnant women.» BMJ 346 (2013): f3140. DOI: 10.1136/bmj.f3140

Rossignol, L., Vaux, S., Maugat, S., et al. «Incidence of urinary tract infections and antibiotic resistance in the outpatient setting: a cross-sectional study (n.d.).» Infection 45.1 (2017): 33–40. DOI: 10.1007/s15010-016-0910-2

Bonkat, R.B.G., Pickard, R. (Co-chairs), et al. EAU Guidelines on Urological Infections, Limited Update (2018). Available from: [https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-Urological-Infections-2018-large-text.pdf ], last accessed Sept 09, 2019.

Anger, J., Lee, U., Ackerman, A.L., et al. «Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline.» J Urol 202 (2019): 282–9. DOI: 10.1097/JU.0000000000000296

Hooton, T.M. «Uncomplicated Urinary Tract Infection.» N Engl J Med 366 (2012): 1028–37. DOI: 10.1056/NEJMcp1104429

Kline, K.A., Lewis, A.L. «Gram-Positive Uropathogens, Polymicrobial Urinary Tract Infection, and the Emerging Microbiota of the Urinary Tract.» Microbiol Spectr 4 (2016). DOI: 10.1128/microbiolspec. UTI-0012-2012

Keren, R., Shaikh, N., Pohl, H., et al. «Risk Factors for Recurrent Urinary Tract Infection and Renal Scarring.» Pediatrics 136 (2015): e13-21. DOI: 10.1542/peds.2015-0409

Guglietta, A. «Recurrent urinary tract infections in women: risk factors, etiology, pathogenesis and prophylaxis.» Future Microbiol 12 (2017): 239–46. DOI:10.2217/fmb-2016-0145

Nicolle, L.E. «Urinary Tract Infections in the Older Adult.» Clin Geriatr Med 32 (2016): 523–38. DOI: 10.1016/j.cger.2016.03.002

Lee, M.J., White, J. «Sexually transmitted causes of urethritis, proctitis, pharyngitis and cervicitis.» Medicine (Baltimore) 46 (2018): 313–8. DOI:10.1016/J.MPMED.2018.03.011

Sarier, M., Kukul, E. «Classification of non-gonococcal urethritis: a review.» Int Urol Nephrol 51 (2019): 901–7. DOI: 10.1007/s11255-019-02140-2

Horner, P.J., Blee, K., Falk, L., et al. «European guideline on the management of non-gonococcal urethritis.» Int J STD AIDS 27 (2016): 928–37. DOI: 10.1177/0956462416648585

Alidjanov, J.F., Naber, K.G., Pilatz, A., et al. «Evaluation of the draft guidelines proposed by EMA and FDA for the clinical diagnosis of acute uncomplicated cystitis in women.» World J Urol (2019): 1–10. DOI: 10.1007/s00345-019-02761-3

Horner, P., Blee, K., O’Mahony, C., et al. «UK National Guideline on the management of non-gonococcal urethritis.» Int J STD AIDS 27 (2016): 85–96. DOI: 10.1177/0956462415586675

Hakenberg, O.W., Harke, N., Wagenlehner, F. «Urethritis in Men and Women.» Eur Urol Suppl. 16 (2017): 144–8. DOI: 10.1016/J.EURSUP.2017.01.002

Mehta, S.D., Rothman, R.E., Kelen, G.D., et al. «Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: a critical population for STD control intervention.» Sex Transm Dis 28 (2001): 33–9. Available from: [http://www.ncbi.nlm.nih.gov/pubmed/11196043], last accessed July 23, 2019.

Shapiro, T., Dalton, M., Hammock, J., et al. «The Prevalence of Urinary Tract Infections and Sexually Transmitted Disease in Women with Symptoms of a Simple Urinary Tract Infection Stratified by Low Colony Count Criteria.» Acad Emerg Med 12 (2005): 38–44. DOI: 10.1111/j.1553-2712.2005.tb01476.x

Behzadi, P., Behzadi, E., Pawlak-Adamska, E.A. «Urinary tract infections (UTIs) or genital tract infections (GTIs)? It’s the diagnostics that count.» GMS Hyg Infect Control 14

(2019). DOI: 10.3205/dgkh000320

Kahlmeter, G., Åhman, J., Matuschek, E. «Antimicrobial Resistance of Escherichia coli Causing Uncomplicated Urinary Tract Infections: A European Update for 2014 and Comparison with 2000 and 2008.» Infect Dis Ther 4 (2015): 417–23. DOI: 10.1007/s40121-015-0095-5

Bader, M.S., Loeb, M., Brooks, A.A. «An update on the management of urinary tract infections in the era of antimicrobial resistance.» Postgrad Med 129 (2017): 242–58. DOI:10.1080/00325481.2017.1246055

Al Majid, F., Buba, F. «The Predictive and Discriminant Values of Urine Nitrites in Urinary Tract Infection.» Biomedical Research 21.3 (2010).

Tomas, M.E., Getman, D., Donskey, C.J., Hecker, M.T. «Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department.» J Clin Microbiol 53 (2015): 2686–92. DOI: 10.1128/JCM.00670-15

Dyar, O.J., Huttner, B., Schouten, J., Pulcini, C. «What is antimicrobial stewardship?» Clin Microbiol Infect 23 (2017): 793–8. DOI: 10.1016/J.CMI.2017.08.026

Khan, F., Arthur, J., Maidment, L., Blue, D.; CIDSC AMU Stewardship Task Group. «Advancing antimicrobial stewardship: Summary of the 2015 CIDSC Report.» Can Commun Dis Rep 42 (2016): 238–41. Available from: [http://www.ncbi.nlm.nih.gov/pubmed/29769993], last accessed Sept 5, 2019.

Kranz, J., Schmidt, S., Lebert, C., et al. «The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients: Part 1.» Urol Int 100 (2018): 263–70. DOI: 10.1159/000486138

Workowski, K.A., Bolan, G.A.; Centers for Disease Control and Prevention. «Sexually transmitted diseases treatment guidelines, 2015.» MMWR Recomm Reports Morb Mortal Wkly Report Recomm Reports 64 (2015): 1–137. Available from: [http://www.ncbi. nlm.nih.gov/pubmed/26042815], last accessed July 10, 2019.

Johnson, J.R., Russo, T.A. «Acute Pyelonephritis in Adults.» N Engl J Med 378 (2018): 48–59. DOI: 10.1056/NEJMcp1702758

Teede, H.J., Misso, M.L., Costello, M.F., et al. «Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome.» Hum Reprod 33 (2018): 1602–18. DOI: 10.1093/humrep/dey256

Kauffman, C.A. «Diagnosis and Management of Fungal Urinary Tract Infection.» Infect Dis Clin North Am 28 (2014): 61–74. DOI: 10.1016/j. idc.2013.09.004

Gharanfoli, A., Mahmoudi, E., Torabizadeh, R., et al. «Isolation, characterization, and molecular identification of Candida species from urinary tract infections.» Curr Med Mycol 5 (2019): 33–6. DOI: 10.18502/cmm.5.2.1159

Hilt, E.E., McKinley, K., Pearce, M.M., et al. «Urine Is Not Sterile: Use of Enhanced Urine Culture Techniques To Detect Resident Bacterial Flora in the Adult Female Bladder.» J Clin Microbiol 52 (2014): 871–6. DOI: 10.1128/JCM.02876-13

Whiteside, S.A., Razvi, H., Dave, S., et al. «The microbiome of the urinary tract – a role beyond infection.» Nat Rev Urol 12 (2015): 81–90. DOI: 10.1038/nrurol.2014.361

Ackerman, A.L., Underhill, D.M. «The mycobiome of the human urinary tract: potential roles for fungi in urology.» Ann Transl Med 5 (2017): 31. DOI: 10.21037/atm.2016.12.69.

Givler, D.N., Givler, A. Asymptomatic Bacteriuria. StatPearls Publishing (2019). Available from: [http://www.ncbi.nlm.nih.gov/pubmed/28722878], last accessed July 23, 2019.

Naber, K.G., Schito, G., Botto, H., et al. «Surveillance Study in Europe and Brazil on Clinical Aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): Implications for Empiric Therapy.» Eur Urol 54 (2008): 1164–78. DOI: 10.1016/J.EURURO.2008.05.010.

Moore, A., Doull, M., Grad, R., et al. «Canadian Task Force on Preventive Health Care, Recommendations on screening for asymptomatic bacteriuria in pregnancy.» CMAJ 190 (2018): E823–E830. DOI: 10.1503/cmaj.171325

LaRocco, M.T., Franek, J., Leibach, E.K., et al. «Effectiveness of Preanalytic Practices on Contamination and Diagnostic Accuracy of Urine Cultures: a Laboratory Medicine Best Practices Systematic Review and Meta-analysis.» Clin Microbiol Rev 29 (2016): 105–47. DOI: 10.1128/CMR.00030-15

Miller, J.M. «Poorly Collected Specimens May Have a Negative Impact on Your Antibiotic Stewardship Program.» Clin Microbiol Newsl 38 (2016): 43–8. DOI: 10.1016/J.CLINMICNEWS.2016.03.001

Lemieux, G., St-Martin, M. «Reliability of clean-voided mid-stream urine specimens for the diagnosis of significant bacteriuria in the female patient.» Can Med Assoc J 98 (1968): 241–5. Available from: [http://www.ncbi.nlm.nih.gov/pubmed/4866850], last accessed Sept 5, 2019.

Miller, J.M., Binnicker, M.J., Campbell, S., et al. «A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiologya.» Clin Infect Dis 67 (2018): 813–6. DOI: 10.1093/cid/ciy584

Baerheim, A., Digranes, A., Hunskaar, S. «Evaluation of urine sampling technique: bacterial contamination of samples from women students.» Br J Gen Pract 42 (1992): 241–3.


GOST Style Citations






Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.

ISSN 2411-1295 (Online), ISSN 2309-4117 (Print)