Philippine Clinical Practice Guidelines

2015 Update

Joshua Miguel B. Ababan

Oscar A. Acopiado, Jr.
UP College of Medicine - Class 2021
Urinary tract infections (UTI) are among the leading indications for seeking
healthcare and using antimicrobials in the community and hospital settings. The
current guidelines further update the recommendations following an extensive
review of more recent literature. The outputs are consensus recommendations
of a panel of clinicians from different societies (PSMID, POGS, PSN, PAFP, PUA).

The focus of this 2015 update will be on Asymptomatic bacteriuria, Recurrent

UTI, and Complicated UTI.
• Defined as bacterial counts more than or equal to
100,000 cfu/mL
– Asymptomatic women: 2 consecutive voided
urine specimens with isolation of the same
bacterial strain
– Men: single, clean-catch voided urine specimen
with one bacterial species isolated
– Both men and women: single catheterized urine
specimen with one bacterial species isolated

• All diagnosis should be based on results of urine

culture specimens that are collected aseptically and
with no contamination.
• Patients who will undergo genitourinary
manipulation and instrumentation
• All pregnant women

*choice of antibiotic depends on culture results

** 7-day regimen is recommended
• All healthy adults
• Patients with diabetes mellitus
• Elderly patients
• Patients with indwelling catheters
• Solid organ transplant patients
• PLHIV
• Spinal cord injury patients
• Patients with urologic abnormalities

LS!!!
PEAR
Pyuria with ASB is not an indication for
antimicrobial treatment among patients
whom screening and treatment is not
recommended
• Urine culture is the gold standard for diagnosing
ASB
• In the absence of facilities with urine culture:
– Significant pyuria (>10 wbc/hpf)*
– Positive gram stain on unspun urine (>2
microorganisms/oif)*
• If (-) pyuria and (-) organisms → no need for urine
CS

*in two consecutive midstream urine samples

• Acute uncomplicated cystitis in a healthy
non-pregnant woman with no known urinary tract
abnormalities as documented by urine culture
– 3 or more episodes in a 12-month period
– 2 or more episodes in a 6-month period

• May either be a relapse or a reinfection

Relapse VS Reinfection

Initial organism persists Infection is caused by a

within the urinary tract different bacterial isolate,
and re-emerges despite OR by the previously
adequate treatment isolated bacteria after a
occurring 1-2 weeks after negative culture or an
stopping treatment adequate period (>= 2
weeks) between
infections
• Recommended for patients in the following
situations:
– No response to appropriate antimicrobial therapy
or rapid relapse after such therapy
– Gross hematuria during a UTI episode OR
persistent microscopic hematuria
– Obstructive symptoms
– Clinical impression of persistent infection
– Infection with urea-splitting bacteria (Proteus,
Morganella, Providencia)
– History of pyelonephritis
– History of or symptoms suggestive of urolithiasis
– History of childhood UTI
– Elevated serum creatinine
• Patients with the factors stated above MAY
BENEFIT from further diagnostic evaluation
• All women with Recurrent UTI should undergo a
complete history and PE first to evaluate urogenital
anatomy and estrogenization of vaginal tissues and
to detect prolapse.

• Renal ultrasound or CT scan/stonogram may be

done to screen for urologic abnormalities
– If with anatomical abnormalities → refer to
specialist (nephrologist or urologist) for further
evaluation
• Recommended in women whose frequency of
recurrence is not acceptable to the patient in levels
of discomfort OR in interference of daily activities

• Factors in determining a patient’s risk-benefit

profile for prophylactic strategies:
– Frequency and pattern of recurrences
– Patient’s lifestyle, compliance and willingness to
commit to a specific regimen
– Plans for pregnancy
– Antimicrobial resistance and susceptibility
pattern of the organism causing the UTI
– Risk of adverse events and drug allergies

• Only initiated after counseling and behaviour

modification have been attempted
• Behavioural changes
– Post-defecation and anal cleansing
antero-posteriorly always in women to avoid
contaminating the periurethral area with fecal
fora
– Post-coital douche or post-coital urination
– Liberal fluid intake especially after intercourse
– Avoidance of tight fitting underwear
– Use of alternative form of contraception for
women using spermicide-containing
contraceptives

• Biologic mediators
– Cranberry products
• Hormonal treatments in post-menopausal women
– Application of intravaginal estriol cream once
each night for 2 weeks
– Use of estradiol releasing silicone vaginal ring for
3 months
– However, there is no insufficient data to
recommend vaginal estrogen over antibiotics for
the prevention of recurrent UTI

• Immunoprophylaxis
– Immunoprophylaxis using immune-active E. coli
fractions
• Once daily per orem for 3 months
• Antibiotic prophylaxis
– Continuous prophylaxis: daily intake of a
low-dose of antibiotic for 6-12 months
– Post-coital prophylaxis: intake of a single dose of
antibiotic immediately after sexual intercourse
– Intermittent prophylaxis: self-treatment with a
single antibiotic dose based on patient’s
perceived need.
• For individual episodes of UTI in women with
recurrent UTI:
– Any of the antibiotics for acute uncomplicated
cystitis may be used
– Consider intermittent self-administered therapy
in highly educated, well-informed, motivated
patients
• Cranberry juice and cranberry products for the
treatment of UTI → NOT RECOMMENDED
• Coconut juice in the prevention and treatment of
UTI → NO AVAILABLE EVIDENCE
• Oral water rehydration (2-2.5 liters/day) in the
prevention or treatment of UTI → INSUFFICIENT
EVIDENCE
• Drinking more water and voiding before and after
intercourse to prevent UTI → INSUFFICIENT
EVIDENCE
• Significant bacteriuria plus clinical symptoms, which
occurs in the setting of:
– Functional or anatomic abnormalities of the
urinary tract or kidneys
– The presence of an underlying disease that
interferes with host defense mechanisms
– Any condition that increases the risk of acquiring
[persistent] infection and/or treatment failure
• Patients with complicated UTI that need
hospitalization:
– Patients with marked debility and signs of sepsis
– Patients in whom there is uncertainty in diagnosis
– Patients in whom there is concern about
adherence to treatment
– Patients who are unable to maintain oral
hydration or take oral medications

• Patients with mild to moderate illness (symptoms of

fever and lower or upper UTI WITHOUT urosepsis,
circulatory failure and/or organ dysfunction or
failure), and those who do not fall under the above
categories may be treated on an OUTPATIENT
basis.
• Urine gram stain and culture and sensitivity
testing must be done before initiating any
treatment

• Imaging of the urinary tract is warranted in the

following cases:
– Pyelonephritis that is not responding to usual
treatment
– Severe pyelonephritis in certain high-risk groups
– Recurrent UTI in a man

• Imaging modality to be used may depend on local

availability
– CT Scan >> KUB ultrasound
• For mild to moderate illness:
– Oral fluoroquinolones OR Amoxicillin/Clavulanic
acid (if there are no risk factors for infection with
antibiotic resistant organisms)

• For severely-ill patients:

– Broad-spectrum parenteral antibiotics which
would depend on:
• Expected pathogens
• Result of urine gram stain
• Current susceptibility patterns
• Risk factors for the acquisition of drug-resistant
organism
– Fluoroquinolones are not recommended as
empiric treatment
• Antibiotic treatment should be at least taken for
7-14 days
– May be extended depending on clinical situation
• Antibiotics are modified according to results of the
urine culture and sensitivity tests
• Outpatient Parenteral Antibiotic Therapy (OPAT)
– When an oral regimen is not available
– If continuation of an IV-administered antibiotic is
necessary
– Criteria:
• Indication for parenteral antibiotic therapy in the
absence of an oral or alternate route of delivery
• No other clinical indication for hospitalization
• Consent of the patient and/or caregiver to
participate
• Outpatient environment safe and adequate to
support care
• After completion of antibiotics:
– Urine culture should be repeated 1-2 weeks after
completion
– If significant bacteriuria persists → refer to
specialists (IDS, Nephro, Uro, etc)
• Diabetic patients require pre-treatment urine GSCS
and a post-treatment urine culture
– Antibiotic therapy of at least 7-14 days (oral or
parenteral)

• If with sepsis → HOSPITALIZATION

– Before starting therapy, get blood culture + urine
culture
– Failure to respond to empiric therapy within
48-72 hours warrants the following:
• Plain abdominal radiograph of the KUB
• Renal ultrasound
• CT-scan

• Screening and treatment for ASB in diabetic

patients → NOT RECOMMENDED
● Diagnosis of CA-UTI
○ Fever or other signs and symptoms of UTI with no
other identifiable source
○ At least 10^3 CFU/mL of at least 1 bacterial
species in a single catheter urine specimen or
midstream voided urine specimen
○ In a patient with an indwelling, suprapubic or
condom catheter or undergoing
catheterization within the previous 48 hrs

● Screening and treatment for asymptomatic cases

not recommended
○ Only for pregnant and will undergo urologic
procedures
○ However data is insufficient for post-solid
organ transplant and neutropenic patients
● Diagnosis of CA-UTI
○ Fever or other signs and symptoms of UTI with no
other identifiable source
○ At least 10^3 CFU/mL of at least 1 bacterial
species in a single catheter urine specimen or
midstream voided urine specimen
○ In a patient with an indwelling, suprapubic or
condom catheter or undergoing
catheterization within the previous 48 hrs

● Screening and treatment for asymptomatic cases

not recommended
○ Only for pregnant and will undergo urologic
procedures
○ However data is insufficient for post-solid
organ transplant and neutropenic patients

● Pyuria alone or presence or absence of odor or

cloudy urine alone are not indications for starting
treatment
● Obtain a urine gram stain and culture before
starting antibiotics
○ Urine should be obtained from the freshly placed
catheter by aspirating from the catheter port or
by puncturing the distal end of the catheter with
a sterile needle
○ If the catheter has been removed, a mid-stream
collection should be obtained
○ All urine should be processed as soon as possible
or refrigerated and used within 24 hrs

● Antibiotics are institution specific and dependent on

local susceptibility patterns

● Remove the indwelling catheter whenever possible

or replace with new catheters before initiating
therapy for UTI
● Periodic assessment of compliances is
recommended

● Alternatives to indwelling catheter:

○ Condom catheter provided post void urine is
minimal and patient has no cognitive impairment
○ Intermittent catheterization but requires a
trained healthcare staff and a cooperative patient
○ Suprapubic catheterization when there are
excellent support mechanisms from the surgical
and caregiver staff

● AVOID
○ Use of antibiotic coated catheters
○ Use of systemic prophylactic antibiotics
○ Catheter or irrigation with antimicrobial agents
○ Addition of antibiotics or antiseptics to drainage
bags and valves
○ Daily meatal care
○ Arbitrarily changing catheters and bags
• Strongly considered in :
– diabetic patients presenting with hypotension
and renal impairment
– Patients suspected to have upper UTI who remain
afebrile and hypotensive 72 hours after initial IV
antibiotic administration

• Diagnostics
– CT scan >> ultrasound
– Urine and blood cultures
– Abscess aspirate culture (if possible)
• Management
– Empiric treatment
• Should have activity against gram-negative
organisms (Escherichia coli, Klebsiella sp., and
Proteus mirabilis)
• Guided by local antimicrobial susceptibility
patterns
– Surgical intervention
• Lesions <5cm - not needed; antibiotics given alone
for 4-10 weeks until abscess has regressed as
evidenced by CT scan
• Lesions >5cm - Percutaneous drainage considered;
if unsuccessful, open drainage should be
considered (antibiotics given for min 4 weeks)
– Vancomycin
• Given if there is another source of infection where
S. aureus is suspected
• Management
– Initial: empiric broad-spectrum antibiotics → If
with cultures, specific therapy initiated
– Patients with early UTI OR UTI with s/sx of
pyelonephritis or sepsis:
• Admitted and started on IV antibiotics
• If with cultures, IV antibiotics → oral
– Late cystitis vs Late pyelonephritis
• Late cystitis: treated for 7 days abx
• Late pyelonephritis: treated for 14 days abx
– Patients with recurrent or relapsing UTI:
• Worked up for any functional or anatomic
abnormalities
• Prophylaxis
– Oral Trimethoprim-sulfamethoxazole
160mg/800mg BID immediately post-transplant
• OD as soon as catheter is removed or
patient is discharged x 6 months
REFERENCES:

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in
Adults 2015 Update: Part 2 Asymptomatic Bacteriuria in Adults, Recurrent Urinary Tract Infection, and
Complicated Urinary Tract Infection.