Hooton Thomas M
Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, WA, USA.
Infect Dis Clin North Am. 2003 Jun;17(2):303-32. doi: 10.1016/s0891-5520(03)00004-7.
Acute uncomplicated UTI is one of the most common problems for which young women seek medical attention and accounts for considerable morbidity and health care costs. Acute cystitis or pyelonephritis in the adult patient should be considered uncomplicated if the patient is not pregnant or elderly, if there has been no recent instrumentation or antimicrobial treatment, and if there are no known functional or anatomic abnormalities of the genitourinary tract. Most of these infections are caused by E. coli, which are susceptible to many oral antimicrobials, although resistance is increasing to some of the commonly used agents, especially TMP-SMX. In women with risk factors for infection with resistant bacteria, or in the setting of a high prevalence of TMP-SMX-resistant uropathogens, a case can be made for using a fluoroquinolone or nitrofurantoin. Use of nitrofurantoin for the empiric treatment of mild cystitis is supportable from a public health perspective in an attempt to decrease uropathogen resistance because it does not share cross-resistance with more commonly prescribed antimicrobials. Beta-lactams and fosfomycin should be considered second-line agents for empiric treatment of cystitis. Acute pyelonephritis in an otherwise healthy woman may be considered an uncomplicated infection. Fluoroquinolone regimens are superior to TMP-SMX for empiric therapy because of the relatively high prevalence of TMP-SMX resistance among uropathogens causing pyelonephritis. TMP-SMX, effective for patients with mild to moderate disease, is an appropriate drug if the uropathogen is known to be susceptible. It is reasonable to use a 7- to 10-day oral fluoroquinolone regimen for outpatient management of mild to moderate pyelonephritis in the setting of a susceptible causative pathogen and rapid clinical response to therapy. Most women with acute uncomplicated pyelonephritis are now managed safely and effectively as outpatients. Acute uncomplicated cystitis or pyelonephritis in healthy adult men is very uncommon but is generally caused by the same spectrum of uropathogens with the same antimicrobial susceptibility profile as that seen in women. The choice of antimicrobials is similar to that recommended for cystitis in women except that nitrofurantoin is not considered a good choice. Treatment duration should generally be longer than that recommended for women.
急性单纯性尿路感染是年轻女性寻求医疗关注的最常见问题之一，会导致相当高的发病率和医疗保健成本。如果成年患者未怀孕或非老年，近期未进行器械操作或接受抗菌治疗，且已知泌尿生殖道无功能或解剖异常，则成人患者的急性膀胱炎或肾盂肾炎应被视为单纯性感染。这些感染大多由大肠杆菌引起，尽管对一些常用药物（尤其是复方磺胺甲恶唑）的耐药性在增加，但大肠杆菌对许多口服抗菌药物敏感。对于有感染耐药菌风险因素的女性，或在复方磺胺甲恶唑耐药尿路病原体患病率较高的情况下，可以考虑使用氟喹诺酮类药物或呋喃妥因。从公共卫生角度来看，使用呋喃妥因经验性治疗轻度膀胱炎是可行的，因为它与更常用的抗菌药物不存在交叉耐药性，有助于降低尿路病原体的耐药性。β-内酰胺类药物和磷霉素应被视为膀胱炎经验性治疗的二线药物。原本健康的女性发生的急性肾盂肾炎可被视为单纯性感染。由于引起肾盂肾炎的尿路病原体对复方磺胺甲恶唑耐药的发生率相对较高，氟喹诺酮类药物方案在经验性治疗方面优于复方磺胺甲恶唑。复方磺胺甲恶唑对轻至中度疾病患者有效，如果已知尿路病原体敏感，则是一种合适的药物。对于轻度至中度肾盂肾炎的门诊管理，在致病病原体敏感且对治疗有快速临床反应的情况下，使用7至10天的口服氟喹诺酮类药物方案是合理的。大多数急性单纯性肾盂肾炎女性患者现在作为门诊患者可得到安全有效的管理。健康成年男性的急性单纯性膀胱炎或肾盂肾炎非常罕见，但通常由与女性相同范围的尿路病原体引起，且抗菌药物敏感性谱相同。抗菌药物的选择与推荐用于女性膀胱炎的药物相似，但呋喃妥因不被认为是一个好的选择。治疗持续时间通常应比推荐用于女性的时间更长。
