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Review Urogenit Tract Infect 2017;12(2):55-64

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The Clinical Guidelines for Acute Uncomplicated Cystitis and Acute

Uncomplicated Pyelonephritis

Ki Ho Kim, Jae Heon Kim1, Seung-Ju Lee2, Hong Chung3, Jae Min Chung4, Jae Hung Jung5, Hyun Sop Choe2, Hun Choi6,
7
Sun-Ju Lee ; The Committee of The Korean Association of Urogenital Track Infection and Inflammation

Department of Urology, Dongguk University College of Medicine, Gyeongju, 1Department of Urology, Soonchunhyang University Seoul
Hospital, Soonchunhyang University College of Medicine, Seoul, 2Department of Urology, St. Vincent’s Hospital, College of Medicine, The
3
Catholic University of Korea, Suwon, Department of Urology, Konkuk University Chungju Hospital, Konkuk University School of Medicine,
4 5
Chungju, Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Department of Urology, Yonsei University Wonju
College of Medicine, Wonju, 6Department of Urology, Korea University Ansan Hospital, Ansan,7Department of Urology, Kyung Hee University
School of Medicine, Seoul, Korea

To date, there has not been an establishment of guidelines for urinary tract Received: 10 April, 2017
infections, due to limited domestic data in Korea, unlike other North American and Revised: 25 April, 2017
Accepted: 25 April, 2017
European countries. The clinical characteristics, etiology, and antimicrobial
susceptibility of urinary tract infections vary from country to country. Moreover,
despite the same disease, antibiotic necessary to treat it may vary from country to
country. Therefore, it is necessary to establish a guideline that is relevant to a specific
country. However, in Korea, domestic data have been limited, and thus, guidelines
considering the epidemiological characteristics pertaining specifically to Korea do Correspondence to: Ki Ho Kim
not exist. Herein, describe a guideline that was developed by the committee of The http://orcid.org/0000-0001-8532-6517
Korean Association of Urogenital Tract Infection and Inflammation, which covers Department of Urology, Dongguk University College
of Medicine, 87 Dongdae-ro, Gyeongju 38067, Korea
only the uncomplicated urinary tract infections, as covering all parts in the first Tel: +82-54-770-8525, Fax: +82-54-770-8503
production is difficult. E-mail: honda400uro@gmail.com

Keywords: Cystitis; Pyelonephritis; Urinary tract infections; Guideline This guideline is a reference for all patients; it may
not be uniformly applicable to all patients. The
clinical judgment should be made on a case-by-case
Copyright 2017, Korean Association of Urogenital Tract Infection and Inflammation. All rights reserved. basis.
This is an open access article distributed under the terms of the Creative Commons Attribution This guideline can be used for personal medical and
Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits educational purposes, but it cannot be used for
unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is commercial purposes or medical examination
properly cited. purposes.

INTRODUCTION from the most recently published Asian Association of UTI

1. Background and Purpose
Urinary tract infections (UTIs) are one of the most
common infectious diseases. They are divided according
to the site of infection, presence or absence of symptoms,
anatomical or functional abnormalities, and the presence
or absence of underlying diseases. The aim of this study
was to develop a guideline for uncomplicated UTIs.
2. Methodology
The guideline presented here is based on the guidelines
& STI (2016), Asian European Association of Urology (2014),
Infectious Diseases Society of America (2011), and AMMI
Canada Guidelines Committee (2005). Major literature
published in Korea was searched using MEDLINE (January
1976 to September 2014), Embase (January 1985 to
September 2014), Cochrane Library (January 1987 to
September 2014), and KoreaMed (January 1958 to September
2014). We used the following keywords to search these
databases: “cystitis,” “pyelonephritis,” “urinary tract
infections,” “necrotizing pyelonephritis,” “pyelonephritides,”
“Korea.”

55
56 Ki Ho Kim, et al. Clinical Guideline for Uncomplicated UTIs
3. Level of Evidence and Grade of the
Recommendation
The level of evidence (LE) and the grade (GR) of
recommendation were accepted and used in accordance
with the recent guidelines of the Oxford Center for
Evidence-Based Medicine.
1) Level of evidence
I: Evidence from at least one randomized controlled trial
II: Evidence obtained from at least one well-designed
controlled study without randomization
III: Evidence obtained from well-designed non-experi-
mental studies, such as comparative studies, correla-
tion studies, and case reports
IV: Evidence obtained from expert committee reports,
opinions, or clinical experience of respected authorities
2) Grade of recommendation
A: Good evidence to support the recommendation for
or against use
B: Moderate evidence to support the recommendation
for or against use
C: Poor evidence to support the recommendation
CLINICAL PRACTICE GUIDELINES BY
DISEASE
1. Acute Uncomplicated Cystitis
Acute uncomplicated cystitis is the most common UTI
occurring mainly in adult women, especially sexually active
young women and postmenopausal women. It is the most
frequently encountered disease in primary medical
institutions, including urology, obstetrics, and gynecology.
More than half of healthy adult women visit the hospital
with acute uncomplicated cystitis at least once in their
lifetime. Escherichia coli is the most common organism
responsible for acute uncomplicated cystitis, followed by
Staphylococcus saprophyticus, Klebsiella pneumoniae, and
Proteus mirabilis. trimethoprim-sulfamethoxazole (TMP-SMX)
or fluoroquinolone was used as an empirical antibiotic.
However, fluoroquinolone-resistant strains and extended
spectrum beta-lactamase (ESBL)-bacteria have increased,
requiring regional antibiotic resistance information and
antibiotic guidelines.
Urogenit Tract Infect Vol. 12, No. 2, August 2017
1) Definition
Acute cystitis is a symptom characterized by lower urinary
tract symptoms, such as discomfort in the pubic area, as
well as storage symptoms, such as pain during urination
without vaginal discharge, urinary frequency, urgency, and
nocturia (LE: 2a, GR: B). There must be no risk factors
that can cause complicated UTIs.
2) Diagnosis
Urine dipstick test and urinary microscopy are widely
used basic diagnostic methods [1]. Although urinalysis is
not mandatory, it is advised to perform a culture test, if
acute pyelonephritis suspicion persists for 2-4 weeks or
there is recurrent cystitis symptoms (LE: 4, GR: B). In Korea,
UTIs have a high rate of resistance to antibiotics. Acute
cystitis is diagnosed when the urine (microscopy, more
than 10 leukocytes) is observed or the colony is more than
10,000 cfu/ml [2,3]. Additional diagnostic studies should
be considered when there is atypical symptoms, fever
without costovertebral angle tenderness, or no response
to treatment (LE: 4, GR: B) [4,5].
3) Treatment
Antibiotic treatment is recommended for patients with
acute cystitis because antibiotics have a significant
therapeutic benefit compared with placebos [6]. Since the
resistance rate of E. coli to fluoroquinolone has already
been reported to be greater than 20% in Korea,
fluoroquinolone should be used carefully to empirically
treat simple UTIs [7,8]. Therefore, in the selection of
empirical antibiotics, it is important to consider the risk
factors of antibiotic resistance in patients, as well as the
tendency to susceptibility of the area. Moreover, antibiotics
should be altered in accordance with clinical features, and
the duration of treatment should be adjusted in accordance
with clinical features and persistence of symptoms.
The criteria for determining empirical antibiotics are as
follows:
• Clinical examination (no clinical symptoms of
pyelonephritis such as high fever and flank pain, the
history of complicated UTIs such as diabetes)
• Spectrum and susceptibility pattern of pathogenic
bacteria
• Therapeutic patterns and antibiotic resistance rates in
the community
 Ki Ho Kim, et al. Clinical Guideline for Uncomplicated UTIs 57

• Availability, tolerability, history of hypersensitivity to clavulanate 500 mg/125 mg oral twice a day, cefaclor 250
drugs, and side effects mg oral three times a day, cefdinir 100 mg oral three times
• Cost a day, cefcapene pivoxil 100 mg oral three times a day,
• Compliance to treatment and cefpodoxime proxetil 100 mg oral twice a day is
A 3-day fluoroquinolone therapy has been widely used recommended (LE: 1, GR: A).
and recommended as an empirical antibiotic treatment for In regions where the resistance rate of E. coli to TMP-SMX
acute cystitis (LE: 1, GR: A). Ciprofloxacin 500 mg oral is less than 20%, it is possible to administer TMP-SMX
bid (twice a day) for 3 days, ciprofloxacin SR 500 mg qd 160/800 mg twice daily for 5 days [12-14] (LE: 1b, GR:
(once a day) for 3 days, and tosufloxacin 150 mg oral B). However, according to a recent multicenter antibiotic
bid are recommended [9] (LE: 1b, GR: B). In Korea, resistance study for UTIs, 30% or more of E. coli identified
fluoroquinolone is not approved to treat acute cystitis, which in patients with acute uncomplicated cystitis is resistant
can lead to insurance-related problems. Due to increased to TMP/SMX, and thus, have limited role as an empirical
resistance to fluoroquinolone, it is important to identify antibiotic (Table 1) [7].
patients with suspected resistance through history taking.
Risk factors for fluoroquinolone resistance is recent history 4) Follow-up
of antibiotic treatment, recent hospitalization history, recent Urinalysis or urine culture in asymptomatic patients is
experience in nursing home care, and chronic respiratory not recommended [12] (LE: 2b, GR: B). Even if urine culture
disease. In any of these cases, it is desirable to select an shows bacteriuria, asymptomatic bacteriuria is not
antibiotic other than fluoroquinolone. Recently, antibiotic recommended for treatment. Exceptionally, antibiotic
therapy that is recommended in many countries, mainly treatment of asymptomatic bacteriuria is recommended only
Europe, instead of fluoroquinolone, is fosfomycin trome- when planning an operation for the urologic urinary tract
tamol 3 g oral single dose therapy, pivmecillinam 400 mg or only in pregnant women. In general, if there is recurrence
oral tid for 3 days, or nitrofurantoin macrocrystal 100 mg within 2 weeks or if symptoms persist for 2 weeks, urine
oral bid for 5-7 days [10,11] (LE: 1a, GR: A). However, culture and antibiotic susceptibility are indispensable.
pivmecillinam and nitrofurantoin are not produced and Moreover, it is recommended to follow the results of the
cannot be used in Korea. antibiotic susceptibility or retreat for more than 7 days with
As a beta-lactam antibiotic, amoxicillin-clavulanic acid a different antibiotic (LE: 4, GR: C) (Fig. 1).
250 mg/125 mg oral three times a day or amoxicillin- An increase in ESBL-producing bacteria has also been
observed with increased resistance to fluoroquinolone in
Korea. ESBL production is mainly seen in E. coli and
Table 1. Empirical antibiotic therapy for acute uncomplicated cystitis Klebsiella strains, and most of them are resistant to
Daily dose Duration of antibiotics, except carbapenem antibiotics, making the
Antibiotic
(oral) therapy (d)
treatment of acute cystitis difficult. Fosfomycin, an oral
Fosfomycin trometamol 3 g qd 1
Pivmecillinama) 400 mg tid 3 antibiotic, should be used when ESBL-producing bacteria
a)
Nitrofurantoin macrocrystal 100 mg bid 5-7 are observed on the urine culture and when empirical
-Lactams
antibiotic therapy fails. In such case, 3 g of fosfomycin
Amoxicillin-clavulanic acid 250/125 mg tid 7
500/125 mg bid trometamol is recommended to be administered three times
Cefaclor 250 mg tid 7 at 48-hour intervals. Amoxicillin-clavulanate can be used
Cefdinir 100 mg tid 5-7
Cefcapene pivoxil 100 mg tid 5-7 in patients where the use of fostomycin is difficult;
Cefpodoxime prexetil 100 mg bid 5-7 additionally, ciprofloxacin or TMP-SMX may also be effective
Fluoroquinolones
if it is susceptible to urine culture (Fig. 2).
Ciprofloxacinb) 500 mg bid 3
500 mg SR qd
b)
Tosufloxacin 150 mg bid 3
2. Acute Uncomplicated Pyelonephritis
qd: once a day, tid: three times a day, bid: twice a day, SR:
sustained-release.
In Korea, amoxicillin, TMP-SMX, and cephalosporin have
a) b)
April 2016, not available in Korea, not available for pregnant women. all been used as the primary treatment antibiotics for UTIs.

Urogenit Tract Infect Vol. 12, No. 2, August 2017

58 Ki Ho Kim, et al. Clinical Guideline for Uncomplicated UTIs
Fig. 1. Algorithm for clinical treatment of acute uncomplicated pyelonephritis. TMP-SMX: trimethoprim-sulfamethoxazole.
However, resistance to these antibiotics has been increasing
as of late; therefore prescribing fluoroquinolone antibiotics,
which have a relatively low resistance rate and can be
used orally, has been on the rise [15-17]. However, resistance
to fluoroquinolone antibiotics has also been increasing; thus,
it is necessary to evaluate and prepare for this as well.
1) Epidemiology
The annual prevalence rate of acute pyelonephritis in
Korea was reported to be 35.7 persons per 10,000 population
between January 1, 1997 and August 30, 1999, according
to the National Health Insurance data, with 59.0 in women
and 12.6 in men. It was reported that 9.96 women and
1.18 men were hospitalized for every 10,000 people. Acute
pyelonephritis in women has been associated with a sudden
Urogenit Tract Infect Vol. 12, No. 2, August 2017
increase in prevalence among patients aged 15 to 25 years,
while remaining stable in those aged 25 to 80 years; in
men, this prevalence seems to increase with age [18].
According to a report in 2007, acute pyelonephritis was
reported in 38.1% of males in their 60s or older and 38.6%
of females in their 20s and 30s [19]. Despite limited data,
recurrence of acute pyelonephritis is 7 per 10,000
population. The mean treatment duration was 8.4 days.
And the mean treatment duration was 7.2 days in outpatients
and 14.1 days in hospitalized patients, with an average
hospital stay of 7.9 days. The mortality rate was 1.2 persons
in 1,000 population; 2.0 males and 1.0 females [18]. In
the case of acute uncomplicated pyelonephritis between
2010 and 2011, according to a multicenter study in Korea,
the mean age was 43 years, with a male to female ratio

of 1:14.4 [20].
2) Diagnosis
(1) Clinical diagnosis: Acute pyelonephritis is a UTI caused
by acute bacterial infection of the renal pelvis and renal
parenchyma, with clinical symptoms of flank pain, nausea,
vomiting, fever of 38 degrees or more, and urinary
symptoms, such as urinary frequency, dysuria, residual urine
sense, and gross hematuria. However, physical examination
may show costovertebral angle tenderness with fever
without urinary symptoms [21]. For this reason, it is difficult
to diagnose acute pyelonephritis only with high fever and
flank pain, requiring further examinations [22]. All patients
suspected of acute pyelonephritis should be evaluated for
multiple factors associated with complicated acute
pyelonephritis, and one of the most important methods
is history taking. Making a distinction between uncom-
plicated and complicated acute pyelonephritis requires
careful history taking at the initial diagnosis of pyelonephritis
since the choice and duration of antibiotics as well as the
need for other treatments are different. However, it is often
difficult to distinguish between uncomplicated and
complicated acute pyelonephritis with only the initial clinical
symptoms. Factors that may cause complicated acute
Ki Ho Kim, et al. Clinical Guideline for Uncomplicated UTIs 59
Fig. 2. Algorithm for clinical management
of acute uncomplicated cystitis (AUC).
UTI: urinary tract infection, ESBL: extended
spectrum beta-lactamase, TMP-SMX:
trimethoprim-sulfamethoxazole.
Table 2. Factors that suggest a potential acute complicated pyelonephritis
[23]
The presence of an indwelling catheter, stent or splint (urethral,
ureteral, renal) or the use of intermittent bladder catheterisation
Post-void residual urine of ＞100 ml
An obstructive uropathy of any aetiology, e.g., bladder outlet obstruc-
tion (including neurogenic urinary bladder), stones and tumor
Vesicoureteric reflux or other functional abnormalities
Urinary tract modifications, such as an ileal loop or pouch
Chemical or radiation injuries of the uroepithelium
Peri- and postoperative urinary tract infection
Renal insufficiency and transplantation, diabetes mellitus and immu-
nodeficiency
pyelonephritis are shown in Table 2 [23].
(2) Laboratory diagnosis: A urinalysis (dipstick method)
is recommended as a basic test (LE: 4, GR: C). A colony
3
count of ＞10 cfu/ml of uropathogens is considered to be
clinically significant, indicating bacteriuria (LE: 2b, GR: C).
The major causative organism of acute pyelonephritis
is E. coli, and from 2000 to 2005, 79% of the 2,910 multicenter
studies in Korea reported E. coli-induced pyelonephritis
[24]. The most common causative organism for acute
pyelonephritis was determined to be E. coli in other
domestic studies. K. pneumoniae, Proteus mirabilis,
Enterococcus strain, and S. saprophyticus have also been
identified [7,17,24-26]. These causative organisms differ in
Urogenit Tract Infect Vol. 12, No. 2, August 2017
60 Ki Ho Kim, et al. Clinical Guideline for Uncomplicated UTIs

distribution, especially according to age. Urine cultures and
susceptibility tests should be performed to promote the
use of antibiotics in a cost effective manner because the
use of inappropriate antibiotics can have serious
consequences (Grade B). However, blood culture tests are
not mandatory and should be performed according to the
circumstances (Grade D). If two or more of the following
conditions are present, blood culture should be performed
o
more than two times: body temperature above 38 C, white
blood cells below 4,000 or above 12,000, heart rate of
less than 90/min, respiratory rate of more than 20/min,
PaCO2 below 32 mmHg, systolic blood pressure below 90
mmHg (Grade C).
The detection of bacteria in the urine culture under clinical
diagnosis of acute pyelonephritis is 46.3-78.8% [24,26]. If
causative organisms are not detected, it can be considered
as one of two things: the infection cannot be cultured after
inoculation on blood agar medium and MacConkey agar
medium, or the antibiotics has been taken from primary
medical institutions or pharmacies. Blood tests may result
in increased neutrophil leukocytosis, elevated erythrocyte
sedimentation rate, increased C-reactive protein (CRP), and
elevated serum creatinine levels associated with renal failure
and decreased creatinine clearance. Recently, procalcitonin
levels in the blood have been reported to be a good predictor
of mortality and sepsis in acute pyelonephritis compared
with the traditional blood markers, such as CRP [27,28].
In women with acute pyelonephritis, blood culture is not
recommended; however, it should be considered if the
complicated acute pyelonephritis is suspected [29]. If there
is persistent fever or flank pain even after 72 hours of
treatment, aggravated acute pyelonephritis or complicated
acute pyelonephritis should be considered. At this time,
blood cultures may be positive.
(3) Imaging test: Ultrasonography must be performed
to evaluate upper urinary tract disorders, such as obstruction
of the urinary tract or renal stone (LE: 4, GR: C). If there
is complaint of persistent fever even after 72 hours of
treatment, unenhanced helical computed tomography,
excretory urography, or dimercaptosuccinic acid renal scans
should be considered as additional tests (LE: 4, GR: C).
Recently, it has been reported that computed tomography
may be more useful than ultrasonography. Especially, the
classification according to the degree of parenchymal
invasion of the contrast enhancement computed
tomography image is associated with the severity and
prognosis of pyelonephritis [30-33].
3) Treatment
Due to the lack of well-designed systematic studies,
treatment for acute uncomplicated pyelonephritis can be
empirical therapy based on the results of UTI pathogens
and antibiotic susceptibility that lead to acute uncomplicated
cystitis (LE: 4, GR: B) [34]. S. saprophyticus, a causative
organism of acute uncomplicated pyelonephritis, is seen
less frequently than acute cystitis (LE: 4, GR: B) (Table 3).
(1) Mild and moderate acute uncomplicated pyelonephritis:
For patients with mild-to-moderate acute pyelonephritis,
10 to 14 days of oral antibiotic therapy is recommended
(LE: 1b, GR: B) (Table 4). Ampicillin, TMP-SMX,
first-generation cephalosporin, and etc., are recommended
as first-line antibiotics for E. coli, which is a major cause
of acute pyelonephritis with high resistance in Korea (Table
5). The resistance rates to E. coli are high with ampicillin
(62.3%), TMP-SMX (36.7-37.2%), and first-generation
cephalosporin (33.9-58.3%). It is not appropriate as a
primary antibiotic for patients with acute uncomplicated
pyelonephritis [24,26]. Fluoroquinolone can be used as a
primary treatment in areas with its resistance rate of around
10% (LE: 1b, GR: A) [35]. In Korea, the resistance rate
of fluoroquinolone (6.9-12.9%) and third-generation
cephalosporin (ex, cefotaxim: 0.8-10.2%) antibiotics is
reported to be around 10% [24,26]. If the dose of
fluoroquinolone is increased, the treatment period may be

Table 3. Initial therapy recommended for severe acute uncomplicated pyelonephritis

Initial therapy LE GR
A parenteral fluoroquinolone, in communities with Escherichia coli fluoroquinolone-resistance rates ＜10%. 1b B
A third-generation cephalosporin, in communities with ESBL-producing E. coli resistance rates ＜10%. 1b B
An aminopenicillin plus a -lactamase-inhibitor in cases of known susceptible Gram-positive pathogens. 4 B
An aminoglycoside or carbapenem in communities with fluoroquinolone and/or ESBLs-producing E. coli resistance rates ＞10%. 1b B
LE: level of evidence, GR: grade, ESBL: extended spectrum beta-lactamase.

Urogenit Tract Infect Vol. 12, No. 2, August 2017

 Ki Ho Kim, et al. Clinical Guideline for Uncomplicated UTIs 61

Table 4. Initial empirical antimicrobial therapy in acute uncomplicated pyelonephritis in premenopausal women (oral therapy: mild and moderate
acute uncomplicated pyelonephritis)
Antibiotics Daily dose Duration of therapy (d) Reference
a)
Ciprofloxacin 500-750 mg bid 7-10 Talan et al. [35]
a)
Levofloxacin 250-500 mg qd 7-10 Richard et al. [41]
Levofloxacin 750 mg qd 5 Klausner et al. [36]
Peterson et al. [37]
Alternative (clinically equivalent to fluoroquinolone but not equivalent to bacteriological effect)
Cefpodoxime proxetil 200 mg bid 10 Cronberg et al. [38]
Ceftibuten 400 mg bid 10 Peterson et al. [37]
If an antibiotic susceptibility test is performed (not appropriate for primary treatment)
Trimethoprim-sulphamethoxazole 160/800 mg bid 14 Rubin et al. [42]
Co-amoxiclavb),c) 0.5/0.125 g tid 14
Bid: twice a day, qd: once a day, tid: three times a day, Co-amoxiclav: amoxicillin-clavulanic acid.
a) b) c)
Lower dose studied, but higher dose recommended by experts, not studied as monotherapy in acute uncomplicated pyelonephritis, mainly for
Gram-positive pathogens.

Table 5. Antibiotic susceptibility (%)

AP SAM AK GM TOB CIP LFX SPT
Antibiotic sensitivity of Escherichia coli and Klebsiella pneumoniae
E. coli 27.2 77.1 92.1 75.5 83.7 79.0 67.4 44.7
K. pneumoniae 43.2 63.5 98.1 97.2 97.3 88.3 66.7 85.6
Antibiotic sensitivity of Gram(-) organisms between 2000 and 2004
2000 year 38.5 79.3 91.7 83.1 85.3 80.2 67.5 59.0
2004 year 18.9 74.4 95.4 72.1 79.1 76.7 65.5 38.1
Adapted from the article of Lee et al. J Korean Med Sci 2009;24:296-301 [19]. Comparison between E. coli and K. pneumoniae (p＜0.05). Comparison
between 2000 and 2004 yr (p＜0.05).
AP: ampicillin, SAM: ampicillin/sulbactam, AK: amikacin, GM: gentamycin, TOB: tobramycin, CIP: ciprofloxacin, LFX: levofloxacin, SPT:
trimetoprim/sulfamethoxazole.

shortened to 5 days (LE: 1b, GR: B) [36,37]. But, considering
the global expression pattern of fluoroquinolone-resistant
E. coli, the use of an initial high dose of fluoroquinolone
should be limited.
Third generation cephalosporins, such as cefpodoxime
proxetil, cefuroxime, and ceftibuten, can be used as an
alternative drug (LE: 1b, GR: B) [36,38,39]. However,
according to the reports to date, there have been clinically
equivalent effects with ciprofloxacin, but bacteriological
and efficacious aspects have not been proven. Considering
that the community resistance rate for Cotrimoxazole is
greater than 10% in most areas, it may not be appropriate
as an empirical therapy; however, it may be considered
if there no resistance as shown on the antimicrobial
susceptibility test (LE: 1b, GR: B) [40]. Amoxicillin-clavulanic
acid is not recommended as a primary treatment agent
(LE: 4, GR: B), but may be selected as a therapeutic agent
if Gram-positive bacteria are cultured in an antimicrobial
susceptibility test (LE: 4, GR: C). In regions where the
resistance rate of fluoroquinolone is high and the resistance
rate of ESBL exceeds 10%, aminoglycosides or carbapenems
can be used as a primary treatment until antibiotic
susceptibility test results are reported (LE: 4, GR: B).
(2) Severe acute uncomplicated pyelonephritis: In
patients with severe acute pyelonephritis, without the
possibility of oral administration due to systemic symptoms,
such as nausea and vomiting, parenteral antibiotics should
be considered as the initial treatment (Table 4) [35-38,41,42].
Hospital admission should be considered if complicating
factors cannot be ruled out in diagnostic procedures or
if patients have clinical signs and symptoms of sepsis (LE:
4, GR: B). After improvement, patients can be switched
to oral therapy, and the treatment should continue for at
least 1-2 weeks (LE: 1b, GR: B).
After improvement, the patient can be switched to an
oral therapy (Table 4) and continue treatment for 1-2 weeks.
Table 6 shows daily dose only [35,36,41,43-47].
4) Follow-up
Urinalysis or urine culture for follow-up in asymptomatic

Urogenit Tract Infect Vol. 12, No. 2, August 2017

62 Ki Ho Kim, et al. Clinical Guideline for Uncomplicated UTIs

Table 6. Initial empirical antimicrobial therapy in acute uncomplicated additional guidelines for UTIs, including recurrent UTIs and
pyelonephritis in premenopausal women (parenteral therapy: severe
complicated UTIs, are needed.
acute uncomplicated pyelonephritis)
Antibiotic Daily dose Reference
Ciprofloxacin 400 mg bid Talan et al. [35] CONFLICT OF INTEREST
a)
Levofloxacin 250-500 mg qd Richard et al. [41]
Levofloxacin 750 mg qd Klausner et al. [36]
Alternative
No potential conflict of interest relevant to this article
Cefotaxime
b)
2 g tid was reported.
Ceftriaxonea),d) 1-2 g qd Wells et al. [43]
b)
Ceftazidime 1-2 g tid Mouton and Beuscart [44]
Cefepime
a),d)
1-2 g bid Giamarellou [45] REFERENCES
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