Urinary Tract Infection

Philippine Society for Microbiology and

Infectious Diseases, Inc.
2nd Floor PSMID Building, 116 9th Avenue, Cubao, Quezon City
Telephone No.: 912-6036, Telefax No.: 911-6986
E-mail: psmidqc@smartbro.net; psmidqc06@yahoo.com.ph
Website: http://www.psmid.org.ph
 Urinary Tract Infection
Philippine Society for Microbiology and
Infectious Diseases, Inc.
2nd Floor PSMID Building, 116 9th Avenue, Cubao, Quezon City
Telephone No.: 912-6036, Telefax No.: 911-6986
E-mail: psmidqc@smartbro.net; psmidqc06@yahoo.com.ph
Website: http://www.psmid.org.ph

Officers and Council of Advisers 2016

President Mari Rose A. De Los Reyes, MD
Vice-President Mario M. Panaligan, MD
Secretary Marissa M. Alejandria, MD
Treasurer Vegloure M. Maguinsay, MD
Business Manager Maria Fe R. Tayzon, MD
Council Members Henry F. Alavaren, MD
Minette Claire O. Rosario, MD, MD
Dionisio M. Tiu, MD
Elfleda A. Hernandez, MD - Cebu
Larissa Lara Q. Torno, MD - Mindanao
Ellamae S. Divinagracia, MD - Western Visayas
Immediate Past President Marie Yvette C. Barez, MD
Council of Advisers Norma H. Abejar, MD
Rosario Angeles T. Alora, MD
Manolito Chua, MD
Remedios F. Coronel, MD
Salvacion R. Gatchalian, MD
Ludovico L. Jurao, Jr., MD
Evelina N. Lagamayo, MD
Mary Ann D. Lansang, MD
Julius A. Lecciones, MD
Ma. Cecilia S. Montalban, MD
Jaime C. Montoya, MD
Mediadora C. Saniel, MD
Rontgene M. Solante, MD
Enrique A. Tayag, MD
Thelma E. Tupasi, MD

UTI Task Force:

Chair Mediadora C. Saniel, MD
Co-Chair Marissa M. Alejandria, MD

ASB in Adults Cluster Recurrent UTI Cluster

Ricardo M. Manalastas Jr., MD (Head) Marissa M. Alejandria, MD
Louella P. Aquino, MD Coralie Therese Dimacali, MD
Shahreza L. Baquiran, MD Leilanie Apostol-Nicodemus, MD
Sybil Lizzane R. Bravo, MD Maria Carmela Lapitan, MD
Jennifer Co, MD Rommel Bataclan, MD
Maria Meden P. Cortero, MD Tennille Tan, MD
Lorina Q. Esteban, MD Mark Brian Tan, MD
Analyn F. Fallarme, MD
May Gabaldon, MD Research Associates
Jill R. Itable, MD
Alfredo M. Lopez, Jr., MD Grace Kathleen Serrano, MD
Helen V. Madamba, MD Richelle Duque, MD
Josefa Dawn V. Martin, MD
Erwin R. de Mesa, MD
Sharon Faith B. Pagunsan, MD
Oliver S. Sanchez, MD
Katha W. Ngo-Sanchez, MD
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Urinary Tract Infection
Algorithm 1: Screening and Treatment of Asymptomatic Bacteriuria

1
Patient with NO
signs or symptoms
of urinary tract
infection

2
3 4 5
Is the patient:
• Pregnant?
• About to undergo Y Screen for ASB Is the result Y Treat based on
genitourinary with urine culture positive? culture results
manipulation/
instrumentation?
N
N 7
6
No need for
No need for treatment
screening and
treatment

Figure 1

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 Urinary Tract Infection
(a) Patients with diabetes mellitus
Philippine Clinical Practice Strong recommendation,
Guidelines on the Diagnosis and Moderate quality of evidence
Management of Urinary Tract (b) Elderly patients
Infections in Adults Strong recommendation,
2014 Update High quality of evidence

(c) Patients with indwelling catheters

Asymptomatic Bacteriuria and Recurrent Weak recommendation,
Urinary Tract Infection Low quality of evidence

Asymptomatic Bacteriuria in Adults - Except in the following special populations

Screening and Treatment
(1) Pregnant patients
Definition Strong recommendation,
Moderate quality of evidence
For asymptomatic women, bacteriuria is defined as

two consecutive voided urine specimens with isola- (2) Those who will undergo urologic procedures
tion of the same bacterial strain in quantitative counts Strong recommendation,
≥100,000 cfu/mL. Moderate quality of evidence
Strong recommendation,
High quality of evidence (3) Those whose bacterial agents cause high
incidence of bacteremia in their institution
In men, a single, clean-catch voided urine specimen
 Weak recommendation,
with one bacterial species isolated in a quantitative Low quality of evidence
count ≥100,000 cfu/mL identifies bacteriuria.
Strong recommendation, (4) Neutropenic patients
High quality of evidence Weak recommendation,
Low quality of evidence
In both men and women, a single catheterized urine

specimen with one bacterial species isolated in a (5) Those that may be part of an infection control
quantitative count ≥100 cfu/mL identifies bacteriuria. plan to manage cluster infections in a unit
Strong recommendation, Weak recommendation,
High quality of evidence Low quality of evidence

• All diagnosis of asymptomatic bacteriuria should (d) Solid organ transplant patients, unless an indwel­
be based on results of urine culture specimens that ling catheter is present
are collected aseptically and with no evidence of Weak recommendation,
contamination. Low quality of evidence
Strong recommendation,
High quality of evidence (e) HIV patients
Weak recommendation,
Indications for screening and treatment: Low quality of evidence

Screening and treatment for asymptomatic bacteriuria

 (f) Spinal cord injury patients
is recommended in the following: Strong recommendation,
Low quality of evidence
(a) All pregnant women.
Strong recommendation, (g) Patients with urologic abnormalities
High quality of evidence Weak recommendation,
Low quality of evidence
(b) Patients who will undergo genitourinary manipula-
tion or instrumentation. Screening tests
Strong recommendation,
High quality of evidence Screening by urine culture is recommended.

Strong recommendation,
Cases where screening and treatment for asymptomatic High quality of evidence
bacteriuria is NOT indicated
In the absence of facilities for urine culture, significant

Routine screening and treatment for asymptomatic
 pyuria (>10 wbc/hpf) or a positive gram stain of un-
bacteriuria is not recommended for healthy adults. spun urine (>2 microorganisms/oif) in two consecutive
Strong recommendation, midstream urine samples can be used to screen for
Low quality of evidence asymptomatic bacteriuria.
Strong recommendation,
Likewise, periodic screening and treatment for
 Low quality of evidence
asymptomatic bacteriuria is not recommended in the
following: Urine culture and sensitivity testing are not necessary


179
Urinary Tract Infection
when urinalysis is negative for pyuria or urine gram Recurrent UTI - Diagnosis
stain is negative for organisms.
Strong recommendation, Definition
Moderate quality of evidence
 Recurrent UTI is diagnosed when a healthy non-preg-
Pyuria accompanying asymptomatic bacteriuria is
 nant woman with no known urinary tract abnormali-
not an indication for antimicrobial treatment among ties has 3 or more episodes of acute uncomplicated
patients for whom screening and treatment is not cystitis documented by urine culture during a 12-
recommended. month period OR 2 or more episodes in a 6-month
Strong recommendation, period.
Low quality of evidence
Recurrent UTI may either be a relapse or a re­infection.

Treatment of Asymptomatic Bacteriuria
° Relapse occurs when the initial organism persists
The choice of antibiotic depends on culture results. A
 within the urinary tract and re-emerges despite
seven-day regimen is recommended. ­adequate treatment usually occurring 1-2 weeks
Strong recommendation, after stopping treatment.
Low quality of evidence

For specific recommendations on pregnant women,


° Reinfection occurs when recurrent UTI is caused
by a different bacterial isolate, or by the previously
­refer to Table 1 and the section on UTI in Pregnancy.
isolated bacteria after a negative intervening culture
or an adequate period (≥2 weeks) between infect­
Table 1. Antibiotics that can be used for asympto­
ions.
matic bacteriuria in pregnancy
Screening
Antibiotics Recommended FDA Risk
dose and Category
Routine screening for urologic abnormalities is not

duration
recommended for the general patient population.
Cephalexin 500 mg BID for B Strong recommendation,
7 days Low quality of evidence
Cefuroxime 500 mg BID for B
axetil 7 days Screening for urologic abnormalities is recommended

in the following situations:
Fosfomycin 3 g single dose B
trometamol
(a) No response to appropriate antimicrobial therapy
Amoxicillin- 625 mg BID for B or rapid relapse after such therapy
clavulanate 7 days
Nitrofurantoin 100 mg QID for B (b) Gross hematuria during a UTI episode or persist-
macrocrystal 7 days; 100 mg ent microscopic hematuria
BID for 7 days for May cause hemo-
monohydrate lytic anemia, (c) Obstructive symptoms
macrocrystal nophthalmia,
formulation hypoplastic left (d) Clinical impression of persistent infection
heart syndrome,
(not available ASD, cleft lip and (e) Infection with urea-splitting bacteria (Proteus,
locally) palate. Morganella, Providencia)

May be given on (f) History of pyelonephritis

the second trimester
of pregnancy until 32 (g) History of or symptoms suggestive of uroli­
weeks AOG. thiasis

Use in the first tri- (h) History of childhood UTI

mester of pregnancy
is appropriate when (i) Elevated serum creatinine
no other suitable
alternative antibiotics Diagnostics
are available
Trimetho- 160/800 mg BID C (avoid in 1st and Radiologic or imaging studies and cystoscopy are not

prim sulfa- for 7 days 3rd trimester) routinely indicated in patients with recurrent UTI.
methoxazole Weak recommendation,
Low quality of evidence

Renal ultrasound or CT scan/stonogram may be done


to screen for urologic abnormalities
Strong recommendation,
Low quality of evidence

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 Urinary Tract Infection
Patients with anatomical abnormalities should be
 (c) Intermittent prophylaxis, defined as self-treat-
referred to a specialist (nephrologist or urologist) for ment with a single antibiotic dose based on
further evaluation. patient's perceived need.
Strong recommendation, Weak recommendation,
Low quality of evidence Low quality of evidence
• Any of the antibiotics in Table 2 given either conti­
Recurrent UTI - Prevention nuously for 6 to 12 months or as post-coital prophylaxis
can reduce the clinical and microbiologic recurrence
Prophylaxis of UTI episodes.
Strong recommendation,
Prophylasis is recommended in women whose fre-
 Moderate quality of evidence
quency of recurrence is not acceptable to the patient
in terms of level of discomfort or interference with
activities of daily living. Table 2. Antibiotics proven effective in reducing
the number of recurrences of UTI
Prophylaxis may be withheld according to patient

preference if the frequency of recurrence is tolerable Antibiotics Recommended doses
to the patient. Conti- Post- Inter-
Strong recommendation, nuous coital mittent
Low quality of evidence prophy- prophy- prophy-
laxis laxis laxis
 The following factors should guide the physician
in determining the patient's risk-benefit profile and Nitrofurantoin 50-100 mg 50-100 mg 50 mg
in deciding which prophylactic strategies will be at bedtime
used: Trimethoprim 100 mg at 100 mg
bedtime
a) Frequency and pattern of recurrences Trimethoprim - 40 mg/ 40 mg/ 40 mg/
sulfamethoxa- 200 mg at 200 mg 200 mg
b) Patient's lifestyle, compliance and willingness to zole bedtime
commit to a specific regimen
Trimethoprim - 40 mg/ 80 mg/
c) Plans for a pregnancy sulfamethoxa- 200 mg 400 mg
zole 3x/week
d) Antimicrobial resistance and susceptibility pattern Ciprofloxacin 125 mg at 200 mg 125 mg
of the organisms causing the patient's previous bedtime
UTI Norfloxacin 200 mg at 200 mg 200 mg
bedtime
e) Risk of adverse events and drug allergies
Ofloxacin 100 mg
Antibiotic prophylaxis Pefloxacin 400 mg
weekly
Antibiotic prophylaxis should only be initiated after
 Cefalexin 125-250 125-250 mg
counseling and behavior modification have been mg at
attempted in order to minimize antibiotic exposure bedtime
and possible adverse effects.
Cefaclor 250 mg at 250 mg
Strong recommendation,
bedtime
Low quality of evidence
Fosfomycin 3 g every
Antibiotic prophylaxis should be limited to women with
 10 days
recurrent UTI in whom non-antimicrobial strategies Amoxicillin 500 mg
have not been effective and who prefer prophylactic Cefuroxime 250 mg
antimicrobial therapy.
Strong recommendation,
Moderate quality of evidence Methenamine salts

If a decision is made to give antibiotic prophylaxis, any

 • Methenamine hippurate may be used as an alternative
of the following is recommended: to antibiotics for short-term prophylaxis (one week) to
prevent UTI in patients without urinary tract abnormali-
(a) Continuous prophylaxis, defined as the daily in- ties.
take of a low-dose of antibiotic for 6-12 months Weak recommendation,
Strong recommendation, Low quality of evidence
Moderate quality of evidence
Behavioral measures to prevent recurrent UTI
(b) Post-coital prophylaxis, defined as the intake of
a single dose of antibiotic immediately after sexual Behavioral measures can be useful antimicrobial-spar-

intercourse ing measures in the prevention of recurrent UTI.
Strong recommendation, Weak recommendation,
Moderate quality of evidence Low quality of evidence

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Urinary Tract Infection
 These behavioral measures include the following:
(a) Post-defecation and anal cleansing antero-pos-
teriorly in women to avoid contaminating the
periurethral area with fecal flora
(b) Post-coital douche or post-coital urination
(c) Liberal fluid intake especially after intercourse
(d) Avoidance of tight-fitting underwear
(e) Use of alternative form of contraception for women
using spermicide-containing contraceptives
Biologic mediators
A. Lactobacilli
 Lactobacilli both in oral form and vaginal supposi-
tories are not recommended in the prevention of
UTI.
Strong recommendation,
High quality of evidence
B. Cranberry products
 Cranberry juice and cranberry products can be
used among patients wherein long-term antibiotic
prophylaxis for recurrent UTI is deemed necessary
to avoid emergence of resistance of fecal and urine
isolates of E. coli to trimethoprim, amoxicillin and
ciprofloxacin.
 The recommended dose for UTI prevention is daily
consumption of 300 mL of cranberry juice cocktail
or 500 mg capsules containing 36 mg PACs taken
twice a day as the anti-adhesion activity decreases
overtime.
Strong recommendation,
Moderate quality of evidence
Table 3. Available cranberry products in the
Philippines
Cranberry Compo- PAC Price per
Products nents component bottle
Cranbiotics Cranberry 120 mg P615/
extract (standard- 60 caps
ized for 30%
PACs)
(Futurebiotics) Oral hydration
Lactobacillus
sporogenes
CranRx Cranberry 500 mg P400/
(Natures way) extract (3x more 30 caps
Standardized
PACs)
Cranberry Cranberry 5,600 mg P410/
concentrate concentrate (700 mg - 90 caps
8:1 extract)
whole Consider intermittent self-administered therapy in
cranberries
(NOW foods) Vitamin C
Sugar
Cranberry Cranberry 500 mg P1,160
GNC Fruit Powder Strong recommendation,
Fontana Cranberry NS P84/1 L
cranberry Vitamin C
juice
182
Hormonal interventions for post-menopausal women
 Application of intravaginal estriol cream once
each night for 2 weeks followed by twice-weekly
applications for at least 8 months OR use of an es-
tradiol-releasing silicone vaginal ring for 3 months
is recommended for the prevention of recurrent
UTI in post-menopausal women
Strong recommendation,
Moderate quality of evidence
 However, evidence is insufficient to recommend
vaginal estrogens over antibiotics for the prevent­
ion of recurrent UTI.
 Low-dose oral estrogen is not recommended for
the prevention of recurrent UTI. Oral estrogens
were associated with coronary heart disease, ve-
nous thromboembolism, stroke and breast cancer.
Strong recommendation,
High quality of evidence
Immunoprophylaxis
 Immunoprophylaxis, using immune-active E. coli
fractions (Urovaxom), is recommended for the
prevention of recurrent UTI. The dosing regimen
is once daily PO for 3 months.
Strong recommendation,
Moderate quality of evidence
 A longer/extended dosing regimen (once daily for 3
months, rest for 3 months, 10 days per month for 3
months, and rest for 3 months) may be associated
with a better control of recurrence in the longer
term.
Weak recommendation,
Moderate quality of evidence
Acupuncture
 Acupuncture on the lower abdomen, back or lower
extremities may be used as an alternative for
prevention of recurrent UTI among women when
antibiotic prophylaxis is contraindicated.
Strong recommendation,
Moderate quality of evidence
 Oral water hydration (2 to 2.5 L/day) may be done
to prevent UTI.
Weak recommendation,
Low quality of evidence
Recurrent UTI - Treatment

highly educated, well-informed, motivated patients,
wherein the patients are able to recognize the charac­
teristic signs and symptoms of UTI, are compliant with
medical insructions and have a good relationship with
a medical provider.
Moderate quality of evidence
Individual episodes of UTI in women with recurrent


UTI or breakthrough infections during prophylaxis
can be treated empirically with any of the antibiot-
ics recommended for acute uncomplicated cystitis
(Table 4) other than the antibiotic being given for
prophylaxis. Always request for a urine culture and
modify the treatment accordingly.
Strong recommendation,
Moderate quality of evidence
Non pharmacologic interventions
 Cranberry juice and cranberry products are not
recommended for the treatment of urinary tract
infection.
Strong recommendation,
Low quality of evidence
 There is no available evidence to recommend
coconut juice in the prevention or treatment of
UTI.
Table 4. Antibiotics for acute uncomplicated cystitis
Antibiotics Recommended from indirect evidence
dose and duration
Primary Nitrofurantoin 100 mg BID for
monohydrate 5 days PO
macrocrystals
(not sold locally)
Nitrofurantoin 100 mg QID for
macrocrystals 5 days PO
Fosfomycin 3 g single dose PO
trometamol
Alternative Pivmecillinam 400 mg BID for
(not sold locally) 3-7 days PO
Ofloxacin 200 mg BID for
3 days PO
Ciprofloxacin 250 mg BID for
3 days PO
Ciprofloxacin 500 mg OD for
extended release 3 days PO
Levofloxacin 250 mg OD for
3 days PO
Norfloxacin 400 mg BID for
3 days PO
Amoxicillin 625 mg BID for
clavulanate 7 days PO
Cefuroxime axetil 250 mg BID for
7 days PO
Cefaclor 500 mg TID for
7 days
Cefixime 200 mg BID for
7 days PO
Cefpodoxime 100 mg BID for
proxetil 7 days PO
Ceftibuten 200 mg BID for
7 days PO
ONLY Trimethoprim- 160/800 mg BID
if with sulfamethoxazole for 3 days PO
proven (TMP-SMX)
suscep-
tibility
Urinary Tract Infection
Table 5. Strength of recommendation and Quality
of Evidence
Category/Grade Definition
Strength of Recommendation
Strong Clear desirable or undesirable
effects
Weak Desirable and undesirable effects
closely balanced or uncertain
Quality of Evidence
High Consistent evidence from well-
performed RCT's or exceptionally
strong evidence from unbiased
observational studies
Moderate Evidence from RCTs with important
limitations or moderately strong evi-
dence from unbiased observational
studies
Low Evidence from ≥ one critical out-
come from observational studies,
from RCTs with serious flaws or
Very Low Evidence for ≥ one critical outcome
from unsystematic clinical observa-
tion or very indirect evidence
Sources:
Task Force on Urinary Tract Infections, Philippine
Practice Guideline Group Infectious Disease. Philippine
Clinical Practice Guidelines on the Diagnosis and
Management of Urinary Tract Infections in Adults 2013
Update. Quezon City, Philippines: PPGG-ID Philippine
Society for Microbiology and Infectious Disease; 2013
Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter
Y, Alonso-Coello P, Schunemann HJ, GRADE Working
Group. GRADE: an emerging consensus on rating quality
of evidence and strength of recommendations. BMJ
2008;336:924-926
Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE,
Liberati A, Schünemann HJ and for the GRADE Working
Group. Going from evidence to recommendations. BMJ
2008;336:1049-51
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Urinary Tract Infection
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ndex of Drugs Related to the Guideline
This index lists the products of interest and/or their therapeutic classifications related to the guideline. This index
is not part of the guideline. For the doctor's convenience, brands available in the PPD references are listed under
each of the classes. For drug information, refer to the PPD references (PPD, PPD Pocket Version, PPD Tabs, and
www.TheFilipinoDoctor.com)�.

Cephalosporins Triocef Pneumocal

First Generation Ultraxime Santis
Cefalexin Cefpodoxime Serlev
Airex Cefadox Teravox
Cefalin Drops / Cefalin Ceftibuten Volekline
Suspension Cedax Wilovex
Ceporex Winthrop Levofloxacin
Oneflex Penicillins Norfloxacin
Pharex Cefalexin Amoxicillin Pharex Norfloxacin
RiteMED Cefalexin Altomox Ofloxacin
Selzef Amoxil/Amoxil Forte Inoflox
Xinflex Globamox Pharex Ofloxacin
Zeporin Globapen Pefloxacin
Second Generation Medvox Peraxin
Cefaclor Pediamox
Aclor Promox Sex (Gonadal) Hormones
Ceclobid RiteMED Amoxicillin Estriol
Ceclor / Ceclor-DS Teramoxyl Ovestin
Cefmed Vhellox 500
Pharex Cefaclor Co-Amoxiclav (Amoxicillin + Sulfonamide Combinations
RiteMED Cefaclor Clavulanic acid) Cotrimoxazole
Cefuroxime Addex (Sulfamethoxazole +
2-Gen Amoclav Trimethoprim)
Altacef Amoclav Suspension Bactille-TS
Altoxime Auget Bactrim
Cefuget Augmentin Globaxol
Cefurex Bactiv Lagatrim Forte
Cimex Bactoclav Onetrim
Cmaxid Bioclavid Pharex Cotrimoxazole
Dinfurox 250 mg/5 mL Cavumox Procor
Susp Clavmoxwel-625 Septrin
Dinfurox 500 mg Tablet Clavoxin Suprex
Dinfurox 750 mg Euroclav Trim-S
Dinoxime 500 mg Pencla Trizole Suspension
Dinoxime 750 mg powd for Pharex Co-Amoxiclav
inj Rafonex Urinary Antiseptics &
Infekor RiteMED Co-Amoxiclav Disinfectants
Kefsyn Sullivan Nitrofurantoin
Medzyme Vamox Macrodantin
Panaxim 250 mg/5 mL Urontin
Granules for Suspension Quinolones
Panaxim 500 mg Tab Ciprofloxacin Other Antibiotics
Panaxim Powder for Inj Ciflobid Fosfomycin
(IM/IV) Ciloxan Monurol
Pharex Cefuroxime Ciprobay/Ciprobay XR
Profurex Ciprofen
Rezafil Wfi Ciprokab
RiteMED Cipromax
Cefuroxime Cipromet
Robisef Cipromet I.V.
Viacef Cirok
Xorimax Cobay
Xyfrox Pharex Ciprofloxacin
Zegen Proxivex
Ziglo RiteMED Ciprofloxacin
Zinacef Xipro
Zinnat Xypen
Third Generation Levofloxacin
Cefixime Ceflox
Dinofix 100mg/5mL Susp Flevoxcin
Flamifix 200 Floxel
Gracefix Glevo I.V
Pharex Cefixime Levocin
RiteMED Cefixime Levoprime
Synmex Lezasin
Tercef 200 Loxeva
Tergecef Pharex Levofloxacin

184