Uncomplicated urinary tract infection is one of the most common indications for antimicrobial exposure in otherwise healthy women. In the past 20 years, antimicrobial resistance among uropathogens has increased dramatically. Overuse of antibiotics has led to ecological adverse effects known as “collateral damage”—specifically, the selection of drug-resistant organisms and the unwanted development of colonization or infection with multidrug-resistant organisms.
Fluoroquinolones have been linked to infection with methicillin-resistant Staphylococcus aureus and increasing fluoroquinolone resistance in gram-negative bacilli, such as Pseudomonas aeruginosa. Extended-spectrum ß-lactamase (ESBL)-producing isolates have been described among patients with acute simple cystitis worldwide (Scand J Prim Health Care 2007; 25:49; Br J Gen Pract 2002; 52:729-34). Broad-spectrum cephalosporins have been linked to subsequent infections with vancomycin-resistant enterococci, ESBL–producing Klebsiella pneumoniae, ß-lactam-resistant Acinetobacter species, and Clostridium difficile.
Recurrent urinary tract infections (rUTIs), defined as two culture-proven UTIs in a 6-month period or three culture-proven events in 1 year, make up a large percentage of UTIs seen in urologic practices. Although the American Urological Association has developed a guideline previously, the current climate of antibiotic overuse and resultant “collateral damage,” as well as the development of antibiotic-resistant organisms, has prompted the need for an updated guideline (J Urol 2019; 202:282-9) that is heavily focused on treating not only symptoms, not only cultures, but rather the important combination of symptoms combined with positive cultures.
Prior to developing the guideline, we conducted a systematic review with the methodology team at the Pacific Northwest Evidence-based Practice Center. The final systematic review was conducted in conjunction with input from the Recurrent Urinary Tract Infection expert panel.
The index patient is an otherwise healthy adult female with an uncomplicated, culture-proven recurrent UTI associated with acute-onset symptoms. Central to a diagnosis of UTI is the symptom of dysuria. Dysuria is a highly specific symptom, with more than 90% accuracy for UTI in young women in the absence of concomitant vaginal irritation or increased vaginal discharge.
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