Guidelines direct treatment for three types of UTIs

Infections are a puzzle for clinicians to solve. Physicians, including urologists, must determine whether treatment is indicated at all, select from a wide range of antimicrobials, consider the community’s level of resistance, and weigh practical issues such as the patient’s availability to have a culture. In this interview, Thomas Hooton, MD, professor of medicine at the University of Miami Miller School of Medicine, discusses these issues in the context of Infectious Diseases Society of America guidelines on three common urologic infections. He was interviewed by Urology Times Editorial Consultant Philip M. Hanno, MD, MPH, professor of urology at the University of Pennsylvania, Philadelphia.

Q: Tell us about your current position and what you do.

Q: Please summarize the bottom line of the guideline on uncomplicated cystitis and pyelonephritis.

A: The first guideline was published in 1999. It was a meta-analysis of treatment trials for uncomplicated cystitis and pyelonephritis that included a very extensive analysis of the published data up to that point. For cystitis, the panel concluded that 3-day therapy was most efficacious. The panel also found that among the drugs that have been shown to be effective in 3-day regimens, trimethoprim-sulfamethoxazole (TMP-SMX [Bactrim, Septra]) was the regimen of choice. Trimethoprim alone appears to be just as effective, but it's not widely used in this country. And then, of course, there are the fluoroquinolones. The fluoroquinolones are highly effective in the treatment of UTI and are recommended in 3-day regimens for the treatment of uncomplicated cystitis.

There's not as much data on pyelonephritis, and the panel's recommendation was that 2 weeks of treatment is sufficient. Some physicians used to prescribe 6 weeks of therapy, but I'm not sure if anyone does that anymore. Around the time the guideline came out, a study was published demonstrating that a 7-day course of ciprofloxacin (Cipro, Proquin XR) was as effective as a longer course of TMP-SMX (JAMA 2000; 283:1583-90). While that paper was not out when the guideline was written, the panel knew of it and recommended that a 7-day regimen was reasonable in individuals with mild to moderate pyelonephritis.

Q: The American Journal of Medicine published a big supplement on UTI in 2002, and I was shocked how it pushed fluoroquinolones. One paper in particular recommended using fluoroquinolones for simple UTIs because of a 10% to 20% resistance rate to some standard antibiotics.

It's not clear what level of resistance for any infection warrants a change in behavior. With regard to what level of resistance to TMP-SMX warrants using an alternative antibiotic, the panel members came up with a range of 10% to 20%, and they recommended that an alternative be considered if you know or you think you know that the resistance prevalence to TMP-SMX in your community is this high, although most of us don't know what the resistance prevalence to antibiotics is in our community. They recommended that nitrofurantoin (Furadantin, Macrobid, Macrodantin) and fosfomycin (Monurol) would probably play a bigger role as TMP-SMX resistance increased over the years. Those are two interesting antibiotics with no cross-resistance with other antimicrobials.