美国妇产科医师学会发布女性尿路感染诊治新指南

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New Guidelines for Management of Urinary Tract Infection in Nonpregnant Women

Release Date: March 17, 2008

March 17, 2008 — The American College of Obstetricians and Gynecologists (ACOG) has issued a practice bulletin to address the diagnosis, treatment, and prevention of uncomplicated acute bacterial cystitis and acute bacterial pyelonephritis in nonpregnant women. The new recommendations are published in the March issue of Obstetrics and Gynecology.

\"An estimated 11% of U.S. women report at least one physician-diagnosed urinary tract infection (UTI) per year, and the lifetime probability that a woman will have a UTI is 60%,\" write Jeanne Sheffield, MD, and colleagues from the ACOG Committee on Practice Bulletins. \"Despite the frequency of UTIs, there is confusion about diagnostic strategies, and changes in antimicrobial resistance among uropathogens require alterations in traditional treatment regimens. The purpose of this bulletin is to address the diagnosis, treatment, and prevention of uncomplicated acute bacterial cystitis and acute bacterial pyelonephritis in nonpregnant women.\"

These guidelines do not address management of complicated UTIs (eg, those occurring in patients with diabetes mellitus, abnormal anatomy, previous urologic surgery, a history of kidney stones, an indwelling urinary catheter, spinal cord injury, immunocompromise, or pregnancy).

Acute bacterial cystitis usually presents with dysuria, urinary frequency and urgency, sometimes with suprapubic pain or pressure, and rarely with hematuria or fever. The symptoms of acute urethritis from Neisseria gonorrhoeae or Chlamydia trachomatis infection, or genital herpes simplex virus type 1 and herpes simplex virus type 2, may be similar, and these conditions should be ruled out.

Upper UTI or acute pyelonephritis often presents with fever, chills, flank pain, and varying degrees of dysuria, urgency, and frequency.

Specific practice recommendations and their accompanying level of scientific evidence are as follows:

-In nonpregnant, premenopausal women, screening for and treatment of asymptomatic bacteriuria is not recommended (level of evidence, A).

-Antibiotic class should be changed when resistance rates are higher than 15% to 20% (level of evidence, A).

-Patients with acute pyelonephritis should complete 14 days of total antimicrobial therapy, regardless of whether treatment is on an inpatient or outpatient basis (level of evidence, A).

-For uncomplicated acute bacterial cystitis in women, including women 65 years and older, antibiotics should be administered for 3 days (level of evidence, A).

-Urine culture is not required for the initial treatment of a symptomatic lower UTI with pyuria or bacteriuria, or both (level of evidence, [Black Eye].

-For the treatment of acute uncomplicated cystitis, beta-lactams, including first-generation cephalosporins and amoxicillin, are less effective than the preferred antimicrobials listed as treatment regimens (level of evidence, C).

-For the diagnosis of bacteriuria in symptomatic patients, decreasing the colony count to 1000 to 10,000 bacteria per milliliter will improve sensitivity without significantly reducing specificity (level of evidence, C).

A proposed performance measure is the percentage of women diagnosed with acute pyelonephritis who receive antimicrobial treatment for 14 days.

For uncomplicated acute bacterial cystitis, recommended treatment regimens are as follows:

-Trimethoprim–sulfamethoxazole: 1 tablet (160 mg trimethoprim–800 mg sulfamethoxazole) twice daily for 3 days. Adverse effects may include fever, rash, photosensitivity, neutropenia, thrombocytopenia, anorexia, nausea and vomiting, pruritus, headache, urticaria, Stevens-Johnson syndrome, and toxic epidermal necrosis.

-Trimethoprim 100 mg twice daily for 3 days. Adverse effects may include rash, pruritus, photosensitivity, exfoliative dermatitis, Stevens-Johnson syndrome, toxic epidermal necrosis, and aseptic meningitis.

-Ciprofloxacin 250 mg twice daily for 3 days, levofloxacin 250 mg once daily for 3 days, norfloxacin 400 mg twice daily for 3 days, or gatifloxacin 200 mg, once daily for 3 days. Adverse effects may include rash, confusion, seizures, restlessness, headache, severe hypersensitivity, hypoglycemia, hyperglycemia, and Achilles tendon rupture (in patients older than 60 years).

-Nitrofurantoin macrocrystals 50 to 100 mg 4 times daily for 7 days, or nitrofurantoin monohydrate 100 mg twice daily for 7 days. Adverse effects may include anorexia, nausea, vomiting, hypersensitivity, peripheral neuropathy, hepatitis, hemolytic anemia, and pulmonary reactions.

-Fosfomycin tromethamine, 3-g dose (powder) single dose. Adverse effects may include diarrhea, nausea, vomiting, rash, and hypersensitivity.

\"A 3-day antimicrobial regimen is now the recommended treatment for uncomplicated acute bacterial cystitis in women, with bacterial eradication rates consistently higher than 90%,\" the authors of the recommendations write. \"Use of trimethoprim–sulfamethoxazole for 3 days is considered the preferred therapy, with a 94% bacterial eradication rate. However, in areas where resistance to this antimicrobial agent exceeds 15-20%, another one of the listed regimens should be chosen.\"

For women with frequent recurrences of lower UTI, continuous prophylaxis has been shown to decrease the risk for recurrence by 95%. Suitable prophylactic regimens include once-daily treatment with nitrofurantoin, norfloxacin, ciprofloxacin, trimethoprim, trimethoprim–sulfamethoxazole, or another agent listed in this article. The need for continued therapy can be re-evaluated after 6 to 12 months.

Although acute pyelonephritis traditionally has been treated with hospitalization and parenteral antibiotics, cost-savings measures have prompted a recent shift to outpatient management, whenever feasible.

\"Imaging of the urinary tract rarely is required in women — it is not cost-effective nor does it provide useful information in the setting of uncomplicated lower or upper UTIs,\" the authors conclude. \"Women with infections that do not respond to appropriate antimicrobial therapy or in whom the clinical status worsens require further evaluation. Renal ultrasonography is the best noninvasive method to evaluate renal collecting system obstruction, [and] an intravenous pyelography also may be useful in this situation.\"

Obstet Gynecol. 2008;111:785-794.
3月17日， 2008日—ACOG (美国妇产科学会)发布公报演讲在非孕妇女非复杂的急性细菌膀胱炎和细菌肾盂肾炎的诊断、治疗和预防的公告。 新的推荐将在3月在妇产科杂志发行出版。
“估计11%美国妇女报告至少每年有一次被医师诊断的尿道感染(UTI)，并且一生中60%妇女可能感染UTI”，ACOG委员会的Jeanne谢菲尔德、MD和同事在实践公报上写到。 ““尽管UTIs频发，但是有关于其诊断战略很混乱，并且在尿路病原体抗菌耐药上的变化应该要求对传统处理进行改变。这份公报发布的目的指导对非孕女的非复杂的急性细菌膀胱炎和的细菌肾盂肾炎的诊断、治疗和预防”。
这些指南不包括复杂的UTIs的管理(即，发生在有糖尿病，异常解剖、早先泌尿道的手术、肾结石的病史，存在一支泌尿导尿管、脊髓伤害、免疫耐受或者怀孕的那些病人)。
急性细菌膀胱炎通常存在尿痛、尿频和尿急，有时与耻骨弓上压痛或压力不适感，和很少伴有血尿或发热。 急性尿道炎的症状与淋病奈瑟(氏)菌或沙眼衣原体传染的或者生殖器泡疹单纯病毒第一类型和单纯疱疹病毒第二类型感染也许是相似的，我们应该排除这些情况。
上尿路感染或急性肾盂肾炎经常出现发热、寒颤、腰部疼痛和不同程度尿痛、尿急和尿频。
具体实践指南和他们伴随的科学证据的水平如下：
在非孕、绝经前的筛选为无症状菌尿的妇女不建议使用本指南(证据级别， A)。
-当抗药性的抵抗率高于15%到20%时应更换抗生素类别(证据级别， A)。
-不论是对住院或门诊的治疗急性肾盂肾炎病人都应完成14天疗程抗生素治疗（证据级别， A） 。
-对的非复杂的急性细菌膀胱炎的妇女，包括妇女65年和更老，应该给予抗生素治疗3天(证据级别， A)。
-对症状的轻的UTI伴有浓尿或菌尿的最初的治疗尿培养没有必要。{证据级别， A)
-对急性非复杂的膀胱炎，包括第一代头孢菌素和阿摩西林β -内酰胺的治疗，作为首选的抗菌剂治疗法不是很有效的(证据级别， C)。
-对有症状菌尿患者诊断菌尿的标准可以减少为每毫升1000年到10,000细菌，这可以增加敏感性，而且没有显著的减少减少特异性(证据级别， C)。
一项拟议绩效措施，是确诊为急性肾盂肾炎的人妇女接受抗生素治疗应为14天。
对于非复杂的急性细菌膀胱炎患者，治疗法建议如下：
-甲氧苄啶–磺胺甲基异噁唑： 1种片剂(160毫克甲氧苄啶–800 mg磺胺甲基异噁唑)每日两次，3天。 副作用可能包括发热、皮疹、光敏、嗜中性白细胞减少症、血小板减少症、厌食，恶心和呕吐，瘙痒、头疼、风疹、Stevens-Johnson综合症状和毒性表皮坏死。
-每日两次甲氧苄氨嘧啶100毫克，3天。 副作用可能包括皮疹、瘙痒、光敏、剥脱性的皮炎、 Stevens-Johnson综合症状、毒性表皮坏死和无菌脑膜炎。
-每日每日两次环丙沙星250毫克，3天，每日两次左氧氟沙星250毫克一次，3天，每日氟哌酸400毫克，3天或者氟哌酸200毫克一次，3天。 副作用包括疹、意识错乱、癫痫发作、坐立不安、头疼、严重过敏症、低血糖症、高血糖症和跟腱破裂(在大于60岁的患者)。
-呋喃妥英、粗晶呋喃妥因50到100毫克每日4的次，7天或者呋喃妥英一水化物100毫克每日两次，7天。 副作用包括厌食，恶心，呕吐，过敏症、周边神经病、肝炎、溶血性贫血和肺反应。
-磷霉素氨丁三醇， 3-g药量(粉末)单次药量。 副作用包括腹泻，恶心，呕吐，皮疹和过敏症。
“现行指南建议中妇女的三天抗菌法对非复杂的急性细菌膀胱炎的细菌清除率的一贯地高于90%”，该指南的作者写道。 “对甲氧苄氨嘧啶–磺胺甲基异噁唑的3天疗法被认为首选的疗法，有94%细菌清除率。 然而，细菌耐药性超出15-20%时应该选择另一个治疗法”。
对于有下尿路感染频繁再现的妇女，连续的预防显示可以减少再发的95%风险。 适当的预防疾病法在这篇文章包括，呋喃妥英、氟哌酸、环丙沙星、甲氧苄氨嘧啶、甲氧苄氨嘧啶–磺胺甲基异噁唑，及其他疗发每日一次。 在持续的治疗6到12月以后再进行评估。
尽管急性肾盂肾炎传统上时住院和肠外抗生素治疗，但是为节约成本起见如果可行的话可以转移到门诊治疗。
“对于泌尿道成像应用到非复杂性下尿路感染和上尿路感染妇女时不必要的，它不能很好的平衡花费和所得到的结果平衡，而且不能提供有用的信息”，作者总结说。 “感染的妇女抗菌疗法不能很好的缓解或临床状态恶化时应要求进一步评估。 肾脏超生波检查法是评估肾脏收集系统阻碍的最佳的非侵入性的方法， [和]在这种情况下一静脉内肾盂造影(术)也许也是有用的”。