Unkomplizierte Harnwegsinfektion – Leitlinienkonforme Behandlung

Zusammenfassung

Harnweginfektionen (HWI) sind häufige Infektionen sowohl im ambulanten als auch stationären Bereich. Im allgemeinen können HWI therapieorientiert in unkomplizierte und komplizierte / nosokomiale HWI unterteilt werden. Zu den unkomplizierten, einfachen HWI zählen die unkomplizierte Zystitis und die unkomplizierte Pyelonephritis. Beide Entitäten werden hauptsächlich durch E. coli verursacht. Allerdings finden sich auch bei den unkomplizierten HWI heutzutage zunehmende Resistenzraten, z. B. gegenüber Aminopenicillinen, Cotrimoxazol und teilweise auch Fluorchinolonen. Diese Entwicklung hat eine Neubewertung der Therapieempfehlungen bei unkomplizierten HWI notwendig gemacht. Bei der unkomplizerten Zystitis wird für die empirische Therapie an erster Stelleß Fosfomycin-Trometamol, Nitrofurantoin oder Pivmecillinam empfohlen. Für die orale Erstlinientherapie der akuten unkomplizierten Pyelonephritis werden Fluorchinolone in hoher Dosierung empfohlen. Die häufigen asymptomatischen Bakteriurien (ASB) müssen mit wenigen Ausnahmen nicht therapiert werden. Aufgrund der zunehmenden Antibiotikaresistenz und des Auftretens multiresistenter Erreger gestaltet sich eine empirische Antibiotikatherapie zunehmend schwieriger. Aus diesen Gründen sollte, wenn immer möglich, die Resistenztestung abgewartet werden. 

Abstract

Urinary tract infections (UTI) are frequent infections in the outpatient and hospital setting. With respect to treatment options, UTI can generally be stratified into uncomplicated and complicated / nosocomial infections. Uncomplicated UTI are represented by the acute uncomplicated cystitis and the uncomplicated pyelonephritis. They are mainly caused by E. coli. There are, however, also increasing resistance rates found in uncomplicated UTI, e. g., against aminopenicillins, cotrimoxazole and increasingly also fluoroquinolones. This development has called for a new evaluation of the treatment recommendations in uncomplicated UTI. As an empirical therapy for uncomplicated cystitis fosfomycin trometamol, nitrofurantoin or pivmecillinam are recommended as first-line agents. As the oral first line therapy for uncomplicated pyelonephritis fluroquinolones in high dosages are recommended. The frequent asymptomatic bacteriuria does not need to be treated, with only a few exceptions. Due to the increasing antibiotic resistance and the emergence of multiresistant uropathogens, empirical antibiotic treatment becomes more difficult. Therefore the results of susceptibility testing should be awaited whenever possible. 

Schlüsselwörter

unkomplizierte Harnweginfektion - Zystitis - Pyelonephritis - Antibiotikaresistenz

Key words

uncomplicated urinary tract infection - cystitis - pyelonephritis - antibiotic resistance

Literatur

• 1 Warren J W, Abrutyn E, Hebel J R et al. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA).  Clin Infect Dis. 1999;  29 745-758
• 2 Gupta K, Hooton T M, Naber K G et al. International clinical practice guidelines for the tretment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. In press. 2010
• 3 Wagenlehner F ME, Schmiemann G, Hoyme U et al. Epidemiologie, Diagnostik, Therapie und Management unkomplizierter bakterieller ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten. S-3 Leitlinie der Arbeitsgemeinschaft Wissenschaftlicher Medizinischer Fachgesellschaften (AWMF) AWMF-Register-Nr 043 / 044 2010 [cited 2010 October]; Available from: http://www.uni-duesseldorf.de/AWMF/
• 4 Grabe M BM, Bjerklund-Johansen T E, Botto H et al. Guidelines on urological infections. In: EAU, editor. European Association of Urology Guidelines. Arnhem, The Netherlands: European Association of Urology; 2010: 1–110
• 5 Truzzi J C, Almeida F M, Nunes E C et al. Residual urinary volume and urinary tract infection--when are they linked?.  J Urol. 2008;  180 182-185
• 6 May M, Brookman-Amissah S, Hoschke B et al. Post-void residual urine as a predictor of urinary tract infection--is there a cutoff value in asymptomatic men?.  J Urol. 2009;  181 2540-2544
• 7 Stern J A, Hsieh Y C, Schaeffer A J. Residual urine in an elderly female population: novel implications for oral estrogen replacement and impact on recurrent urinary tract infection.  J Urol. 2004;  171 (2 Pt 1) 768-770
• 8 Bent S, Saint S. The optimal use of diagnostic testing in women with acute uncomplicated cystitis.  Am J Med. 2002;  113 Suppl 1 A 20 S-28 S
• 9 Little P, Turner S, Rumsby K et al. Developing clinical rules to predict urinary tract infection in primary care settings: sensitivity and specificity of near patient tests (dipsticks) and clinical scores.  Br J Gen Pract. 2006;  56 606-612
• 10 Rothberg M B, Wong J B. All dysuria is local. A cost-effectiveness model for designing site-specific management algorithms.  J Gen Intern Med. 2004;  19 (5 Pt 1) 433-443
• 11 Christiaens T C, De Meyere M, Verschraegen G et al. Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women.  Br J Gen Pract. 2002;  52 729-734
• 12 Ferry S A, Holm S E, Stenlund H et al. Clinical and bacteriological outcome of different doses and duration of pivmecillinam compared with placebo therapy of uncomplicated lower urinary tract infection in women: the LUTIW project.  Scand J Prim Health Care. 2007;  25 49-57
• 13 Falagas M E, Kotsantis I K, Vouloumanou E K et al. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta-analysis of randomized controlled trials.  J Infect. 2009;  58 91-102
• 14 Ferry S A, Holm S E, Stenlund H et al. The natural course of uncomplicated lower urinary tract infection in women illustrated by a randomized placebo controlled study.  Scand J Infect Dis. 2004;  36 296-301
• 15 Johnson L, Sabel A, Burman W J et al. Emergence of fluoroquinolone resistance in outpatient urinary Escherichia coli isolates.  Am J Med. 2008;  121 876-884
• 16 Brown P D, Freeman A, Foxman B. Prevalence and predictors of trimethoprim-sulfamethoxazole resistance among uropathogenic Escherichia coli isolates in Michigan.  Clin Infect Dis. 2002;  34 1061-1066
• 17 Metlay J P, Strom B L, Asch D A. Prior antimicrobial drug exposure: a risk factor for trimethoprim-sulfamethoxazole-resistant urinary tract infections.  J Antimicrob Chemother. 2003;  51 963-970
• 18 Kahlmeter G. An international survey of the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections: the ECO.SENS Project.  J Antimicrob Chemother. 2003;  51 69-76
• 19 Naber K G, Schito G, Botto H et al. Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): implications for empiric therapy.  Eur Urol. 2008;  54 1164-1175
• 20 Zhanel G G, Hisanaga T L, Laing N M et al. Antibiotic resistance in Escherichia coli outpatient urinary isolates: final results from the North American Urinary Tract Infection Collaborative Alliance (NAUTICA).  Int J Antimicrob Agents. 2006;  27 468-475
• 21 Wagenlehner F M, Wagenlehner C, Savov O et al. [Clinical aspects and epidemiology of uncomplicated cystitis in women. German results of the ARESC Study].  Urologe A. 2010;  49 253-261
• 22 Gupta K. Emerging antibiotic resistance in urinary tract pathogens.  Infect Dis Clin North Am. 2003;  17 243-259
• 23 Raz R, Chazan B, Kennes Y et al. Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with a high prevalence of TMP-SMX-resistant uropathogens.  Clin Infect Dis. 2002;  34 1165-1169
• 24 Owens Jr R C, Donskey C J, Gaynes R P et al. Antimicrobial-associated risk factors for Clostridium difficile infection.  Clin Infect Dis. 2008;  46 Suppl 1 19-31
• 25 Paterson D L. “Collateral damage” from cephalosporin or quinolone antibiotic therapy.  Clin Infect Dis. 2004;  38 Suppl 4 341-345
• 26 Nicolle L E, Bradley S, Colgan R et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults.  Clin Infect Dis. 2005;  40 643-654