Clinical Management of Urinary Tract Infection

Abstract

The clinical management of urinary tract infection has changed considerably over the last two decades due to the recognition of several important factors: All urinary tract infections are not the same; in particular, deep tissue infection of the kidney and/or prostate requires a very different form of clinical management than does superficial mucosal infection of the bladder. Consistent with these differences, it is now clear that conventional 7-14 day treatment courses are not ideal for most forms of urinary tract infections; deep tissue infection requires more intensive therapy and superficial mucosal infection needs less intensive therapy. In particular, single dose antimicrobial therapy has been a major advance in the management of the most common form of urinary tract infection--acute uncomplicated urinary tract infection of the adult female; such therapy is safe, effective, inexpensive, and the response provides useful clinical information. The recognition of the etiology of the acute urethral syndrome in most patients (true bacteriuria or Chlamydia trachomatis infection) had led to an effective therapeutic approach to this problem. A logical approach to the problem of recurrent urinary tract infection has emerged that is both cost-effective and clinically effective. Finally, a clearer picture of those populations that would benefit most from anatomical study of the urinary tract has been developed. With these advances, this most common of bacterial infections affecting man throughout his lifespan has become much easier to control.

Optimal Duration of Treatment of Urinary Tract Infections

“…These patients merit antibiotic treatment for eradication of symptoms and possibly also for pre vention of further ascension and invasion. It is in this type of patient, without underlying complicating factors, that single-dose therapy was first shown to be practical and efficacious [4,6,11], To the other requirements for single-dose therapy listed in table II, one might add prompt presentation after onset of symptoms. Patients who present late (at least 6 days after symptoms) are less likely to respond to single-dose therapy [9].…”

“…There is good evidence that single-dose therapy is as effective in uncomplicated infection as longer conventional courses [11,16], Fur thermore, there is a high degree of correlation between failure to respond to single-dose therapy and the pres ence of an underlying abnormality [11]. Thus, single dose treatment provides not only convenient therapy but also a sensitive means to identify children who require radiologic and urologie investigation.…”

“…A comparative assess ment of costs has reported single-dose therapy to be less expensive [3,4], Lack of early bactériologie response to single-dose therapy leads to longer therapy and may her ald a problem that requires further urologie investiga tion. Although the poor yield of such investigation in unselected patients makes it insufficiently cost-effective, the use of response to therapy for pre-screening permits a more satisfactorily cost-effective result [9,11], I shall consider the approach to duration of therapy for urinary tract infection in various specific clinical set tings. I shall limit my discussion to community-acquired infections; the possibilities of antibiotic-resistant patho gens and underlying clinical problems in hospitalized patients with nosocomial infections would necessarily alter one's approach.…”

“…Since asymptomatic bacteriuria in children has a high association with underlying anatomic abnormalities, which may potentiate invasive infection and renal dam age [11], such patients, like pregnant women, are treated for asymptomatic bacteriuria. There is good evidence that single-dose therapy is as effective in uncomplicated infection as longer conventional courses [11,16], Fur thermore, there is a high degree of correlation between failure to respond to single-dose therapy and the pres ence of an underlying abnormality [11].…”

“…There are obvious potential advantages for patients, physicians, and society in the use of single-dose therapy [9,11,12], The assurance of com pliance when a single dose is administered under super vision cannot be matched by outpatients taking medica tions several times daily on their own, especially after symptoms have resolved [6,13]. Single-dose therapy is expected to cause fewer side effects and to alter resident flora less than conventional therapy, simply because of the shorter time of exposure [8].…”