TABLE 903 Cost Comparison of Urinary Antimicrobial Agents 10Day Course

Until the last decade, the duration of antibiotic treatment for a UTI was 7 to 10 days. Multiple studies of shorter treatment regimens for uncomplicated infections in nonpregnant adult women have been published and three days has become the recommended standard.23 and H3 Short-course treatment appears to offer a number of advantages: cost and side effects are substantially reduced, compliance improves, and the development of resistant strains of bacteria is less likely. However, 20 to 30 percent of patients given short-course therapy fail treatment and/or quickly relapse. In addition, three-day regimens are not adequate for all patients and a seven-day course is recommended for pregnant women, those with symptoms over a week, patients with diabetes, individuals who had a previous recent UTI, those who are older than 65 years, and women who use a diaphragm.4

These recommendations for 3-day treatment courses has also generated concern regarding the entity of subclinical pyelonephritis, which has become increasingly apparent during studies of what was felt to be uncomplicated lower UTI.24 Detection of this entity requires sophisticated differentiation based on analysis of immunofluorescent antibody results or analysis for b-glucuronidase and lactate dehydrogenase isoenzymes, principally research tools not available for routine clinical use. In several series, a number of patients with apparent simple cystitis exhibited tissue invasion as demonstrated by the presence of antibody-coated bacteria (ACB), that is, unsuspected or subclinical pyelonephritis. This group had a poor response to short-term therapy when compared to patients with ACB who received 10- to 14-day treatment.4

On the other hand, it has been suggested that short-course treatment may reliably identify patients with subclinical pyelonephritis as available diagnostic tests. This is because a short-course of antibiotics is less likely to eradicate bacteriuria in the patient with tissue invasion. In practice, women with the diagnosis of uncomplicated acute cystitis would be given a three-day course of co-trimoxazole with the expectation of cure in the vast majority. Those patients with recurrence of symptoms, pyuria, and bacteriuria will be promptly identified as having subclinical renal infection necessitating 14 days of therapy.

In certain emergency department settings, especially those serving indigent populations where there is delay in seeking care, the incidence of subclinical pyelonephritis may approach 70 percent of patients. In this circumstance, short-course therapy is difficult to justify. Before the emergency department physician decides to use a three-day course of treatment, the patient's ability to follow up within one week or return if symptoms persist must be assessed. If follow-up compliance is not expected, or the epidemiologic risk of subclinical pyelonephritis is great, then the patient should be placed on a 10- to 14-day regimen.

One should be suspicious that Chlamydia is responsible for symptoms in these settings: a woman with a recent, new sexual partner; a partner with urethritis; examination findings of cervicitis; or when there is low-grade pyuria with no bacteria seen on urinalysis. A seven-day course of doxycycline or a single dose of azthromycin is the preferred treatment.

For recurrent infection, culture and sensitivity tests are essential. 23 and 4 The infection is often due to a new serotype of E. coli, or it may be due to newly resistant organisms that develop as a result of antibiotics excreted into the gastrointestinal tract. Empirical therapy for recurrent infections includes co-trimoxazole, nitrofurantoin macrocrystals, or the fluoroquinolones. However, successful management depends on sensitivity testing. Again, it must be emphasized that these patients need referral when identified as having recurrent infections. In addition to evaluation of the urinary tract, chronic suppressive therapy is usually instituted.

Aggressive therapy is warranted for pregnant women with pyuria or bacteriuria, whether or not associated symptoms are present. Most clinicians prefer a cephalosporin for outpatient treatment. Co-trimoxazole may be considered except within two weeks of the estimated delivery date and in those with glucose-6-phosphate dehydrogenase deficiency. All regimens should be continued for seven days. Inpatient management is stressed for suspected pyelonephritis because the incidence is higher in pregnancy, and maternal and fetal morbidity is substantial.

Adjunctive therapy should include plenty of fluids to enhance diuresis, fruit juices containing vitamin C to acidify the urine, a proper diet, and frequent voiding (at least every two hours) to diminish tissue contact with bacteria.14 Women should be reminded that postintercourse voiding may be helpful in reducing recurrent infection.

Once the infection is eradicated, management should be directed toward prevention of reinfection; up to 80 percent of women who have had one UTI develop another one at a later time. Because many factors are involved in reinfection and some of these are correctable, appropriate referral is essential.

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