Lack of Uniformity Among United States Guidelines for Diagnosis & Management of Acute, Uncomplicated Cystitis
Acute, uncomplicated urinary tract infection (UTI) remains one of the most common bacterial infections seen in inpatient and outpatient clinical settings in the United States. Since uncomplicated UTI is treated in a variety of different settings, guidelines from professional medical societies are expected to be well aligned. Our aim was to compare guidelines for diagnosis and treatment of acute, uncomplicated UTI from medical specialties in the U.S. and confirm uniformity.
The most up to date published guidelines within the fields of family medicine, obstetrics & gynecology, internal medicine, female pelvic medicine & reconstructive surgery, and infectious diseases in the U.S. were reviewed.
All guidelines recommended the use of symptoms and urine dipstick only to diagnose uncomplicated UTI. Some societies did not recommend urine dipstick in cases of recurrent UTI or for patients with classic UTI symptoms with no underlying conditions or competing diagnoses. None recommend the use of urine culture to confirm diagnosis. All guidelines endorsed nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin as first-line agents. Discrepancies existed in the classification of fluoroquinolone and beta-lactam antimicrobials, with most guidelines describing them as second-line, while others considered them first or third-line agents. Amoxicillin and ampicillin, antibiotic agents with high resistance rates in the U.S., were described as important to avoid only by some U.S. guidelines. None mentioned the FDA black box warning for Cipro. (Table available for presentation).
Comparison of guidelines from various specialties revealed important differences in the approach to the treatment of acute, uncomplicated UTI. This lack of uniformity is likely to contribute to the varying clinical management of patients with UTI, emphasizing the need for more consistent guidelines that may improve physician adherence. With few exceptions, urine culture with sensitivity was not recommended for the diagnosis or treatment of UTI by any of the guidelines reviewed. However, the widespread use of empiric antibiotic therapy for UTI can contribute to growing antibacterial resistance pattern in the U.S. and impede efforts for antibiotic stewardship.