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JAID/JSC Updated Guidelines on Cystitis / Pyelonephritis / Urosepsis


JAID/JSC Updated Guidelines on Cystitis / Pyelonephritis / Urosepsis

In 2012, the Japanese Association for Infectious Disease/Japanese Society of Chemotherapy published “JAID/JSC Guide to Clinical Management of Infectious Diseases 2011” to provide practical guidelines for appropriate use of antimicrobials. In 2014, a revised edition titled “JAID/JSC Guide to Clinical Management of Infectious Diseases 2014” was published.The present Guidelines published in 2017 update on previous guidelines.

Cystitis

  • Most urinary tract infections are ascending infections caused by enterobacteriaceae. They are classified into uncomplicated infections associated with no obvious underlying disease and complicated infections with an underlying disease.
  • In premenopausal women with acute cystitis, gram-positive cocci, such as Staphylococcus saprophyticus, are isolated relatively frequently, while Gram-negative E. coli organisms show a 90% or higher susceptibility to penicillins when given in combination with a β-lactamase inhibitor (BLI), cephalosporins, or fluoroquinolones. Therefore, fluoroquinolones may be the first choice when the causative bacterium is unknown or confirmed to be gram-positive cocci, while penicillins with a BLI or cephalosporins are recommended when the urine examination results reveal a gram-negative rod infection (BII).
  • As compared with premenopausal women with acute cystitis, the frequency of isolation of gram-positive cocci is low and isolated E. coli organisms show a high rate of fluoroquinolone resistance in postmenopausal women. Therefore, penicillins with a BLI or cephalosporins are recommended as the first choice (BII), while fluoroquinolones should be selected when the presence of gram-positive cocci has been confirmed.
  • Oral antimicrobials, such as FRPM and FOM, are effective against ESBL-producing bacteria (BII).
  • In cases complicated with cystitis, a urine culture examination should be performed before administration of antimicrobials in order to identify the causative bacterium and examine antimicrobial susceptibility (AII).
  • In cases of recurrent or refractory urinary tract infection, a urine culture examination should be performed after an antimicrobial-free interval of 3 days following termination of any preceding administration of antimicrobials in order to identify the causative bacteria (CIV).

Pyelonephritis

  • Acute uncomplicated pyelonephritis without underlying disease frequently occurs in sexually active women.
  • The causative bacteria are similar to those in cystitis.
  • For treatment:, renally excreted antimicrobials, such as β-lactams and quinolones, are recommended (AI).
  • The effectiveness of empiric therapy is evaluated at 3 days after beginning treatment and switched to definitive therapy when the results of culture testing become available (BII).
  • Parenteral antimicrobial administration is switched to oral administration at 24 h after remission and the total administration period is 14 days (AI).
  • For patients treated as outpatients, when oral antimicrobials are selected for the treatment, a concomitant one-time parenteral administration is also recommended at the initial visit (AI).
  • Abdominal CT scanning is most useful for differential diagnosis of diseases that require urological emergency drainage, such as hydronephrosis, emphysematous pyelonephritis, pyonephrosis, and renal abscess (AII).
  • A urine culture test is essential for demonstration of causative bacteria and evaluation of antimicrobial susceptibility. In patients with sepsis, 2 sets of blood culture samples should be obtained (AII).

Urosepsis

  • Urosepsis is defined as sepsis caused by a severe infection of the urinary tract or male genitalia.
  • While coli is the most frequent causative bacteria, gram-negative rods, such as KlebsiellaProteus, and Serratia, and gram-positive cocci, such as Enterococcus and Staphylococcus, are also observed. Determination of the causative microorganism is difficult without culture test findings (II), thus urine/blood culture and antimicrobial susceptibility testing are essential routine examinations (AIII).
  • SIRS is observed and septic shock may occur, thus monitoring of hemodynamics is necessary (BIV).
  • Renal-excreted β-lactams and fluoroquinolones with a broad spectrum and strong antibacterial activity should be selected (AII). Generally, antimicrobials are given at high doses except in patients with renal dysfunction (AII).
  • In patients with septic shock, intravenous administration of antimicrobials must be initiated as early as possible within 1 h (AII).
  • Urosepsis must be treated by a combination of drainage to relieve stagnation of urine flow, appropriate systemic management, and appropriate antibacterial therapy (AIV).

Salient Points regarding treatment :

  1. Fluoroquinolones should be prescribed when gram-positive cocci are suspected based on urine test findings.
  2. When gram-negative rods have been confirmed by a urine test, the use of fluoroquinolones should be refrained, and cephalosporins or penicillins with BLI are recommended.
  3. Since the fluoroquinolone-resistance rate of E. coli is higher in cystitis in postmenopausal women, cephalosporins or penicillins with BLI are recommended as the first choice in this group.
  4. In cases where there is a history of previous use of antimicrobials and extended-spectrum beta-lactamase (ESBL)-producing bacteria are suspected or have been detected, faropenem (FRPM) or fosfomycin (FOM) should be prescribed.
  5. The preferred treatment for cystitis in pregnant women is cephalosporins for 5 to 7 days.In cases where the causative bacterium shows resistance to cephalosporins, administration of antimicrobials such as CVA/AMPC (clavulanic acid/amoxicillin) and FOM is to be considered.
  6. In premenopausal acute uncomplicated cases of pyelonephritis β-lactams and fluoroquinolones are recommended.
  7. The initial treatment should be evaluated at 3 days after beginning antibacterial treatment and definitive therapy should be initiated when results of culture testing become available. The total duration of antimicrobial administration is   14 days.
  8. In patients with mild/moderate pyelonephritis who can be treated on outpatient basis, a concomitant one-time parenteral administration is also recommended at the initial visit.
  9. For urosepsis,  β-lactams or a broad spectrum fluoroquinolones is recommended. Initially, high doses of antibacterial agents are administered in septic patients followed by selecting the antimicrobial on the basis of antimicrobial susceptibility demonstrated by culture and sensitivity report. The duration of parenteral antibacterial administration is generally 3 to 5 days after resolution of fever or control of complications (eg, pyonephrosis or renal abscess) but in some cases, depending on disease state a longer administration may be necessary.

For further Reference log on to :

  • Yamamoto S, Ishikawa K, Hayami H, et al. JAID/JSC guidelines for clinical management of infectious disease 2015 − urinary tract infection/male genital infection. J Infect Chemother. 2017 Nov;23(11):733-51.


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