New Clinical Practice Guidelines, November 2017

John Anello; Brian Feinberg; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO; Yonah Korngold; John Heinegg; Sam Shlomo Spaeth


November 08, 2017

In This Article

Cystitis / Pyelonephritis / Urosepsis

Japanese Association for Infectious Disease / Japanese Society of Chemotherapy

E. coli organisms isolated from patients with acute uncomplicated cystitis are relatively susceptible to a variety of antimicrobials, while the rate of susceptibility to penicillins administered with beta-lactamase inhibitor (BLI), cephalosporins, and fluoroquinolones is at least 90%, though penicillins alone without BLI are not effective.

Since β-lactams are often ineffective against gram-positive cocci, fluoroquinolones should be prescribed when gram-positive cocci are suspected based on urine test findings. When gram-negative rods have been confirmed by a urine test, the use of fluoroquinolones should be refrained, and cephalosporins or penicillins with BLI are recommended.

Since, in cases of cystitis in postmenopausal women, the fluoroquinolone-resistance rate of E. coli is higher as compared to that in premenopausal women, fluoroquinolones are not recommended, while cephalosporins or penicillins with BLI are recommended as the first choice for postmenopausal women. However, when gram-positive cocci have been detected in a urine test, fluoroquinolones are recommended. If there is a history of previous use of antimicrobials, and extended-spectrum beta-lactamase (ESBL)-producing bacteria are suspected or have been detected, faropenem (FRPM) or fosfomycin (FOM) should be selected.

The usual course of administration for cystitis in pregnant women is cephalosporins for 5 to 7 days, while it is recommended to avoid the use of fluoroquinolones, tetracyclines, and SMZ-TMP (sulfamethoxazole-trimethoprim) in the early stage of pregnancy, and sulfonamides in the late stage. When the causative bacterium shows resistance to cephalosporins, administration of antimicrobials such as CVA/AMPC (clavulanic acid/amoxicillin) and FOM may be considered.

For acute uncomplicated pyelonephritis (premenopausal), renally excreted antimicrobials, such as β-lactams and fluoroquinolones, are recommended. The effectiveness of empiric therapy should be evaluated at 3 days after beginning antibacterial treatment and then switched to definitive therapy when results of culture testing become available. Parenteral administration is switched to oral administration following remission of symptoms such as fever and CVA pain, and antimicrobials are administered for a total of 14 days. Administration of aminoglycosides, which have a narrow safety range, requires caution in patients with insufficient renal function. Therapeutic antimicrobial monitoring (TDM) is performed as necessary. For patients with mild/moderate pyelonephritis who can be treated as outpatients, a concomitant one-time parenteral administration is also recommended at the initial visit.

For urosepsis, renal-excreted β-lactams or fluoroquinolones with a broad antibacterial spectrum and high antibacterial activity are recommended. Generally, septic patients should be treated with high doses of antibacterial agents, except for those with renal dysfunction. Since the causative bacteria are often resistant to antimicrobials, empiric therapy should be initiated with an antimicrobial of broad spectrum, followed by de-escalation therapy by selecting the antimicrobial after the results of antimicrobial susceptibility of causative microorganisms are demonstrated. The prolonged duration of parenteral antibacterial administration is generally 3 to 5 days after resolution of fever or control of complications (eg, pyonephrosis or renal abscess), though a longer administration may be necessary in some cases, depending on disease state.


  • Yamamoto S, Ishikawa K, Hayami H, et al. JAID/JSC guidelines for clinical management of infectious disease 2015 − urinary tract infection/male genital infection. J Infect Chemother. 2017 Nov;23(11):733-51.


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