In Reply

Clinical Practice Guideline: Uncomplicated Bacterial Community-acquired Urinary Tract Infection in Adults—Epidemiology, Diagnosis, Treatment, and Prevention

Uncomplicated urinary tract infections are among the most common bacterial infections. They often trigger a visit to the doctor and therefore contribute crucially to outpatient prescription of antibiotics (1).

The gold standard in diagnosing an uncomplicated urinary tract infection according to the updated AWMF (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, Association of the Scientific Medical Societies in Germany) S3 guideline is the combination of clinical symptoms and urinalysis to determine even low numbers of pathogens, their differentiation, and susceptibility testing. Unfortunately, in routine clinical practice, this gold standard is often not implemented. Reasons given by doctors are a lack of practicality as well as the fact that it is does not make financially sense because the test results become available only after (successful) treatment. In the context of updating the guideline we therefore attempted to develop instruments that at least prevent unnecessary antibiotic prescribing. By using the validated ACSS (Acute Cystitis Symptom Score) questionnaire, the diagnosis of uncomplicated cystitis can be made with a high degree of certainty on the basis of clinical criteria; the severity of the symptoms can be assessed; the course of the infection can be observed; and the effect of the treatment can be measured.

Regular investigations to determine resistance are obviously—as Professor Jantsch correctly comments—essential as they provide the basis for calculated antibiotic treatment. In contrast to the first edition of the guideline, a series of cross-sectional studies to capture the resistance situation in the outpatient setting has become available. This enables a clearly differentiated picture of the resistance situation in uncomplicated infections. Resistance to nitrofurantoin is currently so low that testing would not lead to a change in treatment. The authors of the updated AWMF S3 guideline would welcome attempts to overcome financial and organizational obstacles, whose results should be published.

We unequivocally agree with the comments of Schaumburg, Gatermann, and Becker. Guidelines for the interpretation of resistance tests of mecillinam and nitroxoline to all relevant pathogens should be implemented, and these substances should be included in commercial testing panels. This is a declared objective of the guideline. It should be mentioned here that Enterobacter sp, Citrobacter sp, Staphylococcus sp, and Enterococcus sp are not relevant in uncomplicated urinary tract infections. The focus should be on the most common pathogens causing uncomplicated cystitis.

DOI: 10.3238/arztebl.2018.0192

Dr. med. Jennifer Kranz, FEBU

Klinik für Urologie und Kinderurologie

St. Antonius-Hospital

Akademisches Lehrkrankenhaus der RWTH Aachen

Eschweiler

Dr. Stefanie Schmidt

Dr. Cordula Lebert

Dr. med. Laila Schneidewind

PD Dr. med. Guido Schmiemann

Prof. Dr. med. Florian Wagenlehner

Conflict of interest statement

Prof. Wagenlehner has received consultancy fees from Achaogen, Astra Zeneca, Bionorica, MSD, Pfizer, Rosen Pharma, Vifor Pharma, and Leo Pharma. Furthermore, he has received funds to conduct clinical studies from MSD, Pfizer, Vifor Pharma, Rosen Pharma, and Leo Pharma.

Dr. Kranz has received funds to carry out a systematic review from Leo Pharma.

Dr. Schmidt has received funds to carry out a systematic review from Leo Pharma.

The remaining authors declare that no conflict of interest exists.

References

1. Kranz J, Schmidt S, Lebert C, Schneidewind L, Schmiemann G, Wagenlehner F: Clinical practice guideline: Uncomplicated bacterial community-acquired urinary tract infection in adults—epidemiology, diagnosis, treatment, and prevention. Dtsch Arztebl Int 2017; 114: 866–73