A new consensus statement and clinical practice guidelines published in JAMA Network Open revealed that despite urinary tract infections being among the most common infections globally, high-quality evidence supporting standard practices remain sparse. Of 37 clinical questions examined by the international expert panel, only 6 received clear evidence-based recommendations.

The WikiGuidelines Group, comprising 54 experts from 12 countries (31 physicians, 23 pharmacists/PhDs), conducted systematic reviews of 914 articles. The analysis covered 5 domains: prophylaxis/prevention (7 questions), diagnosis/diagnostic stewardship (7 questions), empirical treatment (3 questions), definitive treatment/antimicrobial stewardship (10 questions), and special populations/genitourinary syndromes (10 questions).

Evidence-Based Recommendations

1. Cranberry products containing 36 mg proanthocyanidins reduced recurrent urinary tract infections (UTIs) in women, children, and high-risk populations. However, evidence was insufficient for older adults, those with bladder emptying problems, or pregnant women.
2. Topical estrogen effectively reduced recurrent UTIs in postmenopausal women.
3. Methenamine hippurate (1 g twice daily) served as an effective antimicrobial-sparing preventive option.
4. For adult acute cystitis, specific treatment durations were supported:
   • Nitrofurantoin: 5 days
   • Trimethoprim/sulfamethoxazole: 3 days
   • Fluoroquinolones: 3 days (for cystitis), 5-7 days (for pyelonephritis)
   • Oral fosfomycin: single dose
   • Pivmecillinam: 3 days
   • β-lactams: 7 days (for pyelonephritis)
5. 7-day treatment courses proved appropriate for gram-negative bacteremia from urinary sources.
6. Routine cystoscopy and urodynamic studies did not require antimicrobial prophylaxis in asymptomatic patients.

Diagnostic Testing Performance

Dipstick testing showed varying reliability:

• Leukocyte esterase: 72-97% sensitivity, 41-86% specificity
• Nitrite: 19-48% sensitivity, 92-100% specificity
• Combined leukocyte esterase/nitrite: 46-100% sensitivity, 42-98% specificity

Imaging modalities demonstrated different efficacy levels:

• Ultrasonography: 74.3% sensitivity, 56.7% specificity
• CT: 81-84% sensitivity, 87.5% specificity
• MRI: 100% sensitivity, 81.8% specificity

Prophylaxis Dosing

The guideline authors specified prophylactic dosing at:

• TMP/SMX: 40 mg/200 mg once daily or 3 times weekly
• Nitrofurantoin: 50 mg or 100 mg daily
• Methenamine hippurate: 1 g twice daily
• Methenamine mandelate: 1 g every 6 hours

Special Population Considerations

The guideline authors identified specific considerations for certain populations:

• In US intensive care units, 25% of UTIs are attributed to Candida species.
• Asymptomatic bacteriuria treatment was only recommended in pregnancy and pre-urologic procedures with expected mucosal bleeding.
• Observational data showed clinical improvement in pediatric cases typically occurring within 48-72 hours of treatment initiation.
• Kidney transplant recipients were advised to avoid asymptomatic bacteriuria treatment after the first 2 months post-transplantation.

Methodology

The WikiGuidelines Group employed stringent criteria, requiring two well-conducted concordant randomized clinical trials, one well-conducted RCT, and a concordant prospective observational study to establish clear recommendations. Literature searches were conducted without date or language restrictions.

Research Gaps

The majority of topics relating to prevention, diagnosis, and treatment lack high-quality prospective data. Specific areas needing further research included optimal diagnostic approaches, the duration of treatment for catheter-associated UTIs, management of UTIs in special populations, treatment of multidrug-resistant organisms, and empirical treatment selection criteria.

Limitations included geographic representation primarily from high-income countries and the influence of local resistance patterns on empiric treatment recommendations. The guideline authors emphasized the need for additional high-quality prospective studies across all aspects of UTI management.

Disclosures can be found in the publihsed guidelines.