Update: Rational antibiotic treatment of outpatient genitourinary infections in a changing environment

Abstract

Listen

Translate article

Urinary tract infections (UTIs) are the most common bacterial infections presenting in the outpatient setting. Choosing the right empiric treatment for genitourinary infections continues to become more difficult due to increases in antimicrobial resistance, shifting and unpredictable regional resistance patterns, and changing etiologies. Even uncomplicated, community-acquired urinary tract infections generally considered easy to treat, are posing therapeutic challenges. UTIs are classified as uncomplicated or complicated. Uncomplicated UTIs occur in sexually active healthy female patients with structurally and functionally normal urinary tracts. Complicated UTIs are those that are associated with structural anatomic abnormalities or comorbid conditions that prolong the need for treatment, increasing the chances for therapeutic failure. All UTIs in male patients are considered complicated as are those that occur in the setting of pregnancy, chemotherapy and/or other immunosuppression. Escherichia coli is generally considered the most common cause of UTI--especially in uncomplicated, community-acquired infections – accounting for 75-95%. Alleviation of symptoms and prevention of complications are short-term treatment goals for UTIs. Long-term goals include prevention of recurrent infection and improvement in rate of reinfection. The Infectious Disease Society of America guidelines currently recommend Nitrofurantoin as first-line therapy for uncomplicated UTIs when local uropathogen resistance to TMP-SMX exceeds 20%, an increasingly common occurrence that underscores the need for clinicians to be aware of resistance patterns in their community. Alternatively, where available and cost-efficient, Fosfomycin or Pivmecillinam should be considered prior to alternative antimicrobial therapy in the form of either fluoroquinolones or beta-lactams. The best approach for treating outpatient UTIs focuses on adapting antimicrobial therapy to rapidly changing bacterial resistance patterns.