Harnwegsinfekt (HWI)

Diese Leitlinie befasst sich mit der asymptomatischen Bakteriurie (ASB) im Allgemeinen und der akuten, unkomplizierten Harnwegsinfektion (HWI) bei erwachsenen, nicht schwangeren Frauen. HWI bei männlichen Patienten, Jugendlichen und Kindern respektive bei Immunsupprimierten oder nierentransplantierten Patienten sind hier ausgeschlossen.

 

Nach Prüfung der aktuellen internationalen Richtlinien empfiehlt das Expertengremium eine Anpassung (1) der im Jahr 2014 herausgegebenen Empfehlungen der Schweizer HWI Richtlinien1 (2) der im Jahr 2011 von der IDSA verfassten und von ESCMID genehmigten Richtlinie zu HWI2 und 3) der im Jahr 2018 von der IDSA verfassten und von ESCMID genehmigten Richtlinie zu ASB.3

 

This guideline addresses asymptomatic bacteriuria (ASB) in general and acute, uncomplicated urinary tract infection (uUTI) in adult non-pregnant women, thus excluding UTI in male patients, adolescents and children, and the immunocompromised with or without renal transplant.

After reviewing current international guidelines, the expert panel (below) recommends the following adaptation of (1) the Swiss UTI recommendations issued in 2014,1 (2) the 2011 IDSA-authored and ESCMID-approved guideline on uUTI,2 and (3) the 2018 IDSA-authored and ESCMID-approved guideline on ASB.3

Bei der asymptomatischen Bakteriurie handelt es sich um die Präsenz von Bakterien (≥105 cfu/mL) im sauber gewonnen Urin in Abwesenheit von typischen Symptomen eines Harnwegsinfektes. Das Screening auf ASB wird in keiner Patientengruppe empfohlen, mit Ausnahme von schwangeren Frauen und bei Patienten mit transurethraler Resektion der Prostata und vor urologischen Eingriffen, bei denen Schleimhautblutungen zu erwarten sind.

Die unkomplizierte HWI ist definitionsgemäss eine Infektion des Urogenitaltraktes und geht einher mit:

  1. Typischen Symptomen (untere Harnwegsinfektion: Dysurie, Pollakisurie, Harndrang oder Hämaturie, suprapubische Druckempfindlichkeit; obere Harnwegsinfektion [Pyelonephritis]: Übelkeit, Erbrechen, Flankenschmerzen, Fieber
  2. Pyurie (> 10 weisse Blutkörperchen [Leukozyten] / mm3 pro Hochleistungsfeld)
  3. Urinkultur mit einem spezifischen Uropathogen (≥103 KBE / mL *).

Nach allgemeinem Konsens ist die Infektion "unkompliziert", wenn keine strukturellen/funktionellen Anomalien der Harnwege bestehen, kein Harnkatheter in situ ist und keine Schwangerschaft oder eine Nierentransplantation im Spiel ist. **

Bei den meisten Fällen sind weder eine Urinanalyse noch eine Urinkultur nötig bei der unteren HWI Erstdiagnose und auch nicht um eine empirische Therapie einzuleiten. Da die Kulturergebnisse länger benötigen, sollte die empirische Therapie für unkomplizierte Harnwegsinfektionen basierend auf der Grundlage von Symptomen eingeleitet werden. Eine Urinkultur ist indiziert bei (1) symptomatischem Rezidiv nach der Therapie oder (2) bei Verdacht auf Pyelonephritis. Auch die Pyurie muss nicht routinemässig dokumentiert werden, da die Pyurie fast immer eine symptomatische Infektion begleitet. Bei atypischen Symptomen und / oder gewissen Zweifeln kann die Pyurie jedoch hilfreich sein, um die Diagnose eines Harnwegsinfektes zu untermauern.

 

ENGLISH:

Asymptomatic bacteriuria (ASB) is the presence of one or more species of bacteria growing in the urine at specified quantitative counts (≥105 cfu/mL), irrespective of the presence of pyuria, in the absence of signs or symptoms typically associated with UTI (see next). Screening for ASB is not recommended in any patient population except pregnant women and those undergoing certain urologic procedures.

Uncomplicated UTI is an infection of the genito-urinary tract confirmed by the presence of:

  1. urinary symptoms (lower UTI: dysuria, urgency, frequency, suprapubic tenderness; upper UTI [pyelonephritis]: nausea, vomiting, flank pain, fever)
  2. pyuria (>10 white blood cells [WPC]/mm3 per high-power field)
  3. a urine culture with an identified uropathogen (≥103 cfu/mL*).

By general consensus, the infection is “uncomplicated” in the absence of an indwelling urinary catheter, baseline urologic abnormalities, pregnancy, and renal transplant or other immunosuppressive states.**

For most cases of suspected lower UTI, laboratory tests (urinalysis, culture) are not required for initial diagnosis and empiric therapy. Because of the predictability of and long turnaround time for culture results, empiric therapy for uncomplicated UTI should be initiated based on symptoms alone. Culture collection is generally necessary only in the case of (1) symptomatic recurrence after therapy or (2) suspected pyelonephritis. Routine measurement of pyuria by urinalysis is also not necessary for diagnosis or management, since pyuria almost always accompanies symptomatic infection. Yet in the case of atypical symptoms and/or some level of doubt, pyuria can be useful to support the diagnosis of UTI.

 

Asymptomatic bacteriuria should not be treated with antibiotics unless diagnosed during pregnancy or before certain urologic procedures (see IDSA 2018 guidelines for recommendations).3

Antibiotic-sparing approaches in the age of resistance:

  • Lower UTI: Up to one half of cystitis cases will ultimately resolve spontaneously4-6 (though antibiotic therapy accelerates resolution significantly), and in some women untreated cystitis does not appear to significantly increase risk of progression to pyelonephritis.7 Thus in the age of antimicrobial resistance, new antibiotic-sparing approaches can be attempted for select patients (no prior history of pyelonephritis and symptom duration ≤5 days) before resorting to antibiotic therapy:
    • Standby therapy: the physician prescribes an antibiotic for later use “as needed”, encouraging the patient first to try symptomatic therapy (for 48h) with increased hydration and paracetamol or non-steroidal anti-inflammatories (NSAID) such as ibuprofen.
    • Delayed prescription: the physician prescribes a NSAID for at least 48h; the patient returns if symptoms persist.
  • Pyelonephritis: Pyelonephritis is a systemic illness requiring prompt antibiotic therapy (see next).

 

ZystitisKommentar

DEUTSCH HIER...

 

 

First-line:

  • nitrofurantoin§ po 100 mg bid for 5 days or
  • trimethoprim/sulfamethoxazole* (TMP/SMX) po 160/800 mg bid for 3 days

 

Second line (allergy or resistance to first-line therapy):

  • fosfomycin po 3g (single dose)** or
  • norfloxacin*** po 400 mg bid for 3 days or
  • cefuroxime**** po 500 mg bid for 7 days or
  • amoxicillin-clavulanate**** po 500/125 mg tid for 3 days

DEUTSCH HIER...

 

 

§Though rarely observed in practice, early studies indicate a potential risk for hemolysis in patients with glucose-6-phosphate dehydrogenase deficiency.8 Nitrofurantoin should be used with caution in this population.

*20-30% of clinical urinary isolates in Switzerland are resistant to TMP/SMX, but these are likely not representative of the strains infecting a patient presenting with a non-recurrent, uncomplicated lower UTI.  

**Fosfomycin proved inferior to nitrofurantoin in a recent randomized trial9 but may still be a useful strategy for patients with few antibiotic options.

***This quinolone is effective but comes with a high ecologic cost (perturbation of the intestinal microbiota with increased emergence of resistant strains).10

****Oral beta-lactams should be used with caution as they generally have slightly inferior efficacy and may have more adverse effects.

PyelonephritisKommentar

DEUTSCH HIER...

 

Patient stable:

  • ciprofloxacin* po 500 mg bid for 7 days

 

Patient unstable or pre-treated with a quinolone:

  • ceftriaxone* iv 1g qd until antibiogram available or
  • gentamicin iv 5 mg/kg qd until antibiogram available

*

DEUTSCH HIER...

 

*Ciprofloxacin and ceftriaxone have significant ecologic costs (development of resistance in the intestinal microbiota).10

 

PyelonephritisKommentar

DEUTSCH HIER...

 

  • TMP/SMX po 160/800 mg bid for a total antibiotic duration of 7-14* days or
  • ciprofloxacin po 500 mg bid for a total antibiotic duration of 7* days or
  • amoxicillin po 875/125 mg bid for a total antibiotic duration of 7-14* days or
  • cefuroxime po 500 mg bid for a total antibiotic duration of 7-14* days

DEUTSCH HIER...

 

Targeted therapy will be guided by antibiogram results. In general, the physician should choose the antibiotic with the narrowest spectrum (e.g., amoxicillin for a multi-susceptible Escherichia coli strain) and thus (theoretically) the least potential for ecologic damage.

*There is strong evidence that a 7-day course of ciprofloxacin is efficacious,11 but less direct evidence that 7 days suffice for other antimicrobials, so caution is warranted and shorter durations should be reserved for those with more rapid initial responses.

 

DEUTSCH HIER

 

During consultation for the active UTI, preventive strategies to avoid additional UTIs should be discussed. Modifiable behavioral practices should be addressed; in particular the use of spermicides should be avoided.

There is now little evidence that cranberry juice successfully prevents UTI; topical estrogen for postmenopausal infections appears to have variable efficacy (rates of 0-30%).12

The sugar D-mannose was recently studied in an open-label randomized clinical trial comparing it (1:1:1) with either nitrofurantoin or no prophylaxis for prevention of recurrent UTI.13 Among the 308 women included and followed for six months, 15 (15%) in the D-mannose group, 21 (20%) in nitrofurantoin group, and 62 (61%) in the no-prophylaxis group experienced a UTI (p<.001 for both treatment arms). Larger, double-blind studies with longer follow-up are warranted.

Probiotics and vaccination strategies remain investigational.

Quellen / Referenzen:

1.         Hasse B. et al. Traitement des infections urinaires simples, 2014, SG-Inf : http://www.sginf.ch/guidelines/guidelines-overview.html

2.         Gupta K, Hooton TM, Naber KG et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52: e103-20.

3.         Nicolle LE. Clinical practice guidelines for the management of asymptomatic bacteriuria: 2018 update by the Infectious Diseases Society of America. Clin Infect Dis 2018: (in press).

4.         Gagyor I, Bleidorn J, Kochen MM et al. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial. BMJ 2015; 351: h6544.

5.         Christiaens TC, De Meyere M, Verschraegen G et al. Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. Br J Gen Pract 2002; 52: 729-34.

6.         Kronenberg A, Butikofer L, Odutayo A et al. Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomised, double blind trial. BMJ 2017; 359: j4784.

7.         Falagas ME, Kotsantis IK, Vouloumanou EK et al. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta-analysis of randomized controlled trials. J Infect 2009; 58: 91-102.

8.         Chan TK, Todd D, Tso SC. Drug-induced haemolysis in glucose-6-phosphate dehydrogenase deficiency. Br Med J 1976; 2: 1227-9.

9.         Huttner A, Kowalczyk A, Turjeman A et al. Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women: A Randomized Clinical Trial. JAMA 2018; 319: 1781-9.

10.       Stewardson AJ, Vervoort J, Adriaenssens N et al. Effect of outpatient antibiotics for urinary tract infections on antimicrobial resistance among commensal Enterobacteriaceae: a multinational prospective cohort study. Clin Microbiol Infect 2018; 24: 972-9.

11.       Sandberg T, Skoog G, Hermansson AB et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet 2012; 380: 484-90.

12.       Barclay J, Veeratterapillay R, Harding C. Non-antibiotic options for recurrent urinary tract infections in women. BMJ 2017; 359: j5193.

13.       Kranjcec B, Papes D, Altarac S. D-mannose powder for prophylaxis of recurrent urinary tract infections in women: a randomized clinical trial. World J Urol 2014; 32: 79-84.

 

Members of the SSI Expert Committee on uncomplicated UTI:

Tatiana Galperine: CHUV, Lausanne
Barbara Hasse: USZ, Zurich
Andreas Kronenberg : Inselspital, Bern
Angela Huttner: HUG, Geneva (chair)

 

Antibiotika richtig einsetzen

⇒ Beachte Patientenfaktenblatt der Pharmasuisse, FMH und des BAG

 

Referenzguidelines (Grundlage für SSI-Version):

  1. Behandlung von unkomplizierten Harnwegsinfektionen (Hasse et al.), 2014. SG-Inf
  2. Gupta K, Hooton TM, Naber KG et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52: e103-20.
  3. Nicolle LE. Clinical practice guidelines for the management of asymptomatic bacteriuria: 2018 update by the Infectious Diseases Society of America. Clin Infect Dis 2018: (in press).