New UTI Guideline Offers Treatment Clarity, but Reveals Pressing Gaps in Research

New recommendations from the WikiGuidelines collaborative published in JAMA Network Open offer strategies for the prevention, diagnosis, and management of urinary tract infections (UTIs) in children and adults.

While the guideline covers a range of clinical topics, including prophylaxis and antimicrobial stewardship, many key clinical questions remain unanswered due to a lack of high-quality evidence, according to lead author Zachary Nelson, PharmD, MPH, of HealthPartners and Park Nicollet Health Services, St. Louis Park, Minnesota, and colleagues.

“This guideline fills a critical gap by providing pragmatic, broadly applicable recommendations tailored for generalist care and systems-based practice,” Nelson and coauthors wrote. “Our guidance is rooted in the best available evidence and is designed for clinicians from various backgrounds and healthcare environments. It emphasizes a patient-centered approach to the diagnosis, prevention, and treatment of UTIs and related genitourinary infections.”

WikiGuidelines has previously published guidance on infective endocarditis and pyogenic osteomyelitis. For the new UTI guidance, Nelson and 53 other members of the collaborative from 12 countries developed it in accordance with Standards of Quality Improvement Reporting Excellence and the WikiGuidelines charter. The latter “requires issuing clear recommendations only when supported by sufficient hypothesis–confirming evidence, including 2 well-conducted concordant randomized clinical trials (RCTs) or 1 well-conducted RCT and a well-conducted concordant prospective observational study,” authors wrote.

Researchers reviewed 914 articles to provide information on 5 areas of UTI care: prophylaxis and prevention; diagnosis and diagnostic stewardship; empirical treatment; definitive treatment and antimicrobial stewardship; and special populations and genitourinary syndromes. Nelson and colleagues were able to provide clear recommendations for 6 out of 37 unique questions, and partial recommendations for another 3. This was primarily due to a lack of high-quality, hypothesis-confirming evidence available for those specific questions, the group noted.

Preventive strategies

The consensus strongly recommends cranberry products containing proanthocyanidins (36 mg) to reduce recurrent UTIs in women and children. However, data are insufficient to recommend them for older adults, those with bladder issues, or pregnant women.

Topical estrogen is recommended for postmenopausal women with recurrent UTIs, as it helps restore the vaginal microbiome with minimal systemic absorption. It may also benefit patients with breast cancer when nonhormonal alternatives fail, according to researchers.

For girls and women who do not have incontinence and have intact bladder anatomy, methenamine hippurate is suggested as a noninferior alternative to low-dose antibiotics for preventing recurrent UTIs.

Empirical treatment strategies

Nelson and colleagues concluded that empirical treatment for UTIs should have “historically demonstrated efficacy and safety in the treatment of UTIs, achieve adequate urinary concentrations, and provide reliable activity against the most common pathogens based on local resistance rates.”

Trimethoprim/sulfamethoxazole (TMP/SMX) or a first-generation cephalosporin are considered reasonable first-line agents for treating pyelonephritis. The choice should be guided by local resistance rates. Also, the group recommended nitrofurantoin for uncomplicated cystitis. For intravenous therapy, ceftriaxone is preferred unless there are risk factors for multidrug resistance.

Antimicrobial stewardship

The guideline emphasizes antimicrobial stewardship, with support for antibiotic de-escalation and oral regimens where feasible, to reduce adverse effects and hospital stays. Despite limited evidence, Nelson and coauthors suggest thorough allergy assessment and selective reporting of susceptibility results to enhance antibiotic selection.

While data were insufficient to make clear recommendations about the treatment of asymptomatic bacteriuria, authors suggested that this practice “risks side effects without benefit” while threatening antimicrobial sustainability.

Special considerations for urologic procedures

Patients undergoing urologic procedures, routine cystoscopy, and urodynamic studies generally do not require prophylactic antibiotics, authors concluded. Single-dose antibiotic prophylaxis is recommended for low-risk patients undergoing percutaneous nephrolithotomy, although high-risk individuals (ie, pregnant women, patients with kidney transplant) may require extended prophylaxis.

The 3 partial recommendations included:

• Pharmacotherapy for prevention. While pharmacotherapy can be considered for the prevention of UTIs in women with recurrent infections, the evidence quality is insufficient to make a clear recommendation. This includes the use of antibiotics and other preventive measures.
• Duration of treatment for pediatric cystitis and pyelonephritis: There is insufficient evidence to provide a clear recommendation for the duration of treatment for pediatric cystitis and pyelonephritis. Observational data suggest that shorter durations (3 to 5 days for cystitis and 5 to 9 days for pyelonephritis) may be effective, but the heterogeneity in existing studies precludes a definitive recommendation.
• Empirical treatment for catheter-associated urinary tract infections (CAUTI): The guideline authors found insufficient quality of evidence to provide a clear recommendation for empirical treatment of CAUTI, therefore treatment decisions should be individualized based on the patient's specific circumstances.

“Pressing research gaps remain, including the need for high-quality studies to validate novel diagnostic methods, optimize treatment durations, establish standard definitions, and refine antimicrobial stewardship strategies for asymptomatic bacteriuria and MDROs,” Nelson et al concluded. “Suggestions for alternative evidence or recommendations are welcome for consideration by the authors, with updates to the guideline made as needed. No single guideline can encompass all clinical scenarios; therefore, this document is not intended to set legal medical standards or replace professional judgment for individual patient cases.”

Reference: Nelson Z, Tarik Aslan A, et al. Guidelines for the prevention, diagnosis, and management of urinary tract infections in pediatrics and adults: A WikiGuidelines group consensus statement. JAMA Netw Open. Published online November 4, 2024. doi:10.1001/jamanetworkopen.2024.44495