The Philippine Clinical Practice Guideline on the Diagnosis and ...

<strong>The</strong> <strong>Philippine</strong> <strong>Clinical</strong> <strong>Practice</strong> <strong>Guideline</strong> on the Diagnosis 

and Management of Urinary Tract Infections: 

A Quick Reference Guide for Clinicians* 

Report of the Task Force on Urinary Tract Infections 

1998 

(*Editors note: <strong>The</strong> Task Force on Urinary Tract Infections plan to meet in the last quarter of this year to lay out plans 

to review the guideline. <strong>The</strong> Task Force plans to finish before the end of year 2004. <strong>The</strong> summaries of evidence were 

omitted for this quick reference. <strong>The</strong> summaries of evidences are in the complete guideline pamphlet available at the 

PSMID office.) 

INTRODUCTION 

Urinary tract infections (UTIs) are among the most common infections encountered by physicians. In 

clinics of tertiary centers in Manila, Cavite and Zamboanga, they account for 5 to 17% of consultations. <strong>The</strong> 

<strong>Philippine</strong> Renal Disease Registry of the <strong>Philippine</strong> Society of Nephrology reports chronic pyelonephritis as the cause 

of end stage renal disease in 11% of patients undergoing maintenance dialysis and 8% of kidney transplant patients 

from six centers. UTI’s also constitute over 40% of hospital-acquired infections. 

<strong>The</strong> clinical practice guidelines, (CPGs) on UTI’s are formulated to assist practitioners in the diagnosis, 

treatment and prevention of UTI in adults. <strong>The</strong> targeted users are general practitioners, family physicians and 

specialists. 

To cover the various important issues on UTI management, recommendations are provided for each of the 

following eight clinical syndromes, which differ from one another in terms of clinical presentation, epidemiologic 

setting and requirements for antimicrobial therapy: acute uncomplicated cystitis, acute uncomplicated pyelonephritis, 

asymptomatic bacteriuria, UTI in pregnancy, recurrent UTI, complicated UTI, UTI in men and catheter-associated 

UTI. 

<strong>The</strong>se recommendations are based on evidence derived from critical review of existing data and utilize 

modifications of the quality standards of the Infectious Diseases Society of America (IDSA). <strong>The</strong>y are given 

alphabetical ranking to reflect their strength. 

<strong>The</strong> standards are not intended to supplant good clinical judgment. This caveat applies to all 

recommendations, particularly those for which there is inadequate evidence for or against their use (Grade C). Despite 

lack of quality evidence, some recommendations which are based on clinical experience, descriptive studies and/or 

consensus reports of expert committees have been provided to specifically address common problems which confront 

health care providers and their patients. [Phil J Microbiol Infect Dis 2002; 31(1):27-44] 

Key Words: urinary tract infections, guideline, practice guideline 

I. ACUTE UNCOMPLICATED CYSTITIS IN WOMEN 

1. Definition 

1.1 Acute uncomplicated cystitis in women is defined as growth of ≥ 100 colony forming units 

(cfu)/ml of mid-stream urine (msu) in non-pregnant women (18 to 50 years old), presenting 

with. (a) any of the following symptoms: dysuria, frequency, urgency, gross hematuria, or 

hypogastric pains; and (b) without symptoms of vaginitis, pyelonephritis, and risks factors for 

subacute pyelonephritis or complicated UTI (Table 1) (Grade A). For inclusion of patients in 

clinical trials, a diagnostic criterion of > 1,000 cfu/ml is recommended (Grade C). 

Note: A table summarizing laboratory criteria for significant bacteriuria and pyuria for various UTI syndromes is 

found in Appendix 3. Laboratory criteria are based on the requisite that urine specimens are properly collected and 

handled (see Appendix 4). 

1.2 In the absence of a urine culture, the laboratory diagnosis of acute cystitis can be determined 

by the presence of significant pyuria defined as: (a) 8 or more pus cells/ mm 3 of uncentrifuged

urine; or (b) 5 or more pus cells/hpf of centrifuged urine; or (c) positive leukocyte esterase test 

and nitrite test (Grade C). 

Note. Pyuria per se is not automatically equated with UTI. Other important causes are listed in Appendix 5. 

Table 1. Risk factors for subacute pyelonephritis or complicated UTI 

Hospital acquired infection 

Indwelling urinary catheter 

Recent urinary tract infection 

Recent urinary tract instrumentation (in the past 2 weeks) 

Functional or anatomic abnormality of the urinary tract 

Recent anti-microbial use (in the past 2 weeks) 

Symptoms for > 7 days at presentation 

Diabetes mellitus 

Immunosuppression 

2. Pre-treatment diagnostic tests 

Pre-treatment urine culture and sensitivity is not recommended (Grade E). Standard urine 

microscopy using a hemocytometer and dipstick leukocyte esterase and nitrite tests are not 

prerequisites for treatment (Grade D). 

3. Duration of treatment 

A 3-day course of anti-microbial therapy is effective. However, patients should be 

advised to come back if symptoms persist or recur (Grade C). 

Table 2. Three-day regimen for acute uncomplicated cystitis 

TMP/SMX 1601800 mg BID 

Nitrofurantoin 100 mg QID 

Norfloxacin 400 mg BID 

Ciprofloxacin 250 mg BID 

Pefloxacin 400 mg BID 

Ofloxacin 200 mg BID 

Co-amoxiclav 375 mg TID 

4. Choice of Antibiotics 

Any of the antimicrobials listed in Table 2 can he used (Grade A). Ampicillin and 

amoxicillin should not be used (Grade E). In areas where trimethoprim/sulfamethoxazole 

(TMP/SMX) resistance is not a problem, the first line drug is still TMP/SMX. <strong>The</strong> recommended 

antimicrobials may change depending on the local patterns of susceptibility. Cost and side effects 

are additional factors to he considered in the choice (Grade C). (See Appendix 6 for costs of 

antimicrobial regimens) 

5. Post-treatment follow-up 

5.1 Routine post-treatment urine culture and urinalysis in asymptomatic patients are not 

recommended (Grade C). 

5.2 Patients whose symptoms worsen or do not improve after 3 days should have a urine culture 

and the antimicrobial should be empirically changed, pending result of sensitivity testing (Grade 

C).

5.3 Patients whose symptoms improve but do not completely resolve after 3 days should 

complete a 7-day course of the same antimicrobial. Patients whose symptoms fail to resolve 

after the 7-day treatment should be managed like a complicated urinary tract infection [(see 

Section VI) (Grade C)]. 

II. ACUTE UNCOMPLICATED PYELONEPHRITIS 


<strong>The</strong> classic syndrome of acute uncomplicated pyelonephritis (AUPN) is characterized by 

fever (>38 o C), chills, flank pain, cost vertebral angle tenderness, nausea and vomiting, with or 

without signs and symptoms of lower urinary tract infection (dysuria, frequency, urgency and 

hematuria) in an otherwise healthy female with no clinical or historical evidence of structural or 

functional urologic abnormalities (Rubin 1992). Laboratory findings include pyuria (> 5 wbc/hpf 

of centrifuged urine) and bacteriuria with counts of > 10,000 cfu of an uropathogen/ml in culture 

of voided urine (Rubin 1992, Roberts 1986). 

2. Etiologic Diagnosis 

2.1 Gram stain of uncentrifuged urine is recommended to differentiate gram-positive from gramnegative 

bacteria, the result of which can guide choice of empiric therapy (Grade C). Quantitative 

urine culture and sensitivity test should also he performed routinely to allow for more precise and 

cost-effective use of antimicrobial agents and because of the potential for serious sequelae if an 

inappropriate antimicrobial regimen is used (Grade C). 

2.2 Blood cultures (done twice) are recommended for those who are ill enough to require 

hospitalization, particularly those with suspected sepsis (Grade C). 

3. Treatment 

Premise: <strong>The</strong> main therapeutic objectives are to eradicate organisms invading the renal 

parenchyma and to anticipate the need to treat bacteremia and prevent metastatic infection. 

Choice of antimicrobial regimen depends on the locally prevailing sensitivity patterns of common 

uropathogens, case of administration and relative costs. 

3.1 Outpatient vs. inpatient therapy. Non-pregnant patients with no signs and symptoms of sepsis, 

who are compliant and are likely to return for follow-up if symptoms do not resolve, may be 

treated as outpatients (Grade C). <strong>The</strong> following are indications for admission: inability to 

maintain oral hydration or take medications; concern about compliance; uncertainty about the 

diagnosis; severe illness with high fever, severe pain, marked debility and signs of sepsis (Grade 

C). 

3.2 Selection of antimicrobial therapy. Several regimens, which have been found to be effective, 

are recommended [(see Table 3) (Grades A-B)]. <strong>The</strong> aminopenicillins (ampicillin or amoxicillin) 

and first-generation cephalosporins are not recommended (Grade E). If there is increasing 

resistance to TMP/SMX in the area, this drug is also not recommended (Grade E). Combining 

ampicillin with an aminoglycoside offers no added benefit, except when enterococcal infection is 

suspected (Grade C). <strong>The</strong> choice of continued antibiotic therapy should be guided by the urine 

culture and sensitivity result once available (Grade C).

3.3 Route of administration. Patients with mild to moderate symptoms can he treated with oral 

antimicrobials for the total duration of treatment (Grade B). Parenteral therapy is recommended 

for initial management of patients who may have severe infection (presence of chills, fever, 

vomiting with or without shock) and for patients with nausea, vomiting or ileus (Grade C). 

Switching to an oral regimen is appropriate once the patient is a febrile for at least 24 hours and is 

able to take the drug orally (Grade C). 

3.4 Duration of <strong>The</strong>rapy. <strong>The</strong> recommended duration of therapy for AUPN is 14 days for most 

antimicrobials, except for ciprofloxacin for which 7 days is sufficient (Grade A). Treatment for 

longer than 14 days has no added benefit and is not recommended (Grade E). 

Table 3. Treatment regimens for uncomplicated acute pyelonephritis 

Characteristic Pathogens <strong>Clinical</strong> Situation Recommended Empiric Treatment 

E. coli, 

P. mirabilis, 

K. pneumoniae, 

S. saprophyticus 

Mild-to-moderate illness, 

no nausea or vomiting, 

- outpatient therapy 

Severe illness or 

possible urosepsis 

- hospitalization required 

Oral* 

fluoroquinolone, TMP/SMX or co-amoxiclav for 14 days 

Parentereral** 

aminoglycoside, fluoroquinolone or third generation 

cephalosporin until fever is gone (usually after 24-48 hrs), 

then 

oral fluoroquinolones or TMP/SMX to complete 14 days 

*Oral regimens: ciprofloxacin 500 mg every 12 hours; ofloxacin 200 mg every 12 hours; norfloxacin 400 mg 

every 12 hours; lomefloxacin 400 mg once a day; TMP/SMX 160/800 mg every 12 hours; co-amoxiclav 625 mg. 

every 8 hours. Ciprofloxacin may be given for seven days (see Section 3.4). 

**Parenteral regimens: ceftriaxone 1-2 g once a day; ciprofloxacin 200-400mg every 12 hours; ofloxacin 200-400 

mg every 12 hours; gentamicin 3-5 mg/kg once a day or 1 mg/kg every 8 hours. 

4. Work-up for urologic abnormalities 

Routine urologic evaluation and routine use of imaging procedures are not recommended 

(Grade D). Radiologic evaluation should he considered if the patient remains febrile within 72 

hours of treatment to rule out the presence of nephrolithiasis, renal or perirenal abscesses, or other 

complications of pyelonephritis, or if there is recurrence of symptoms (Grade C). Urologic 

consultation should be obtained if deemed appropriate (Grade C). 

5. Follow-up cultures during and post-therapy 

In patients who are clinically responding to therapy (usually apparent in < 72 hours after 

initiation of treatment), there is no need for a follow-up urine culture (Grade C). Routine posttreatment 

cultures in asymptomatic patients are also not indicated except in patients who initially 

present with sepsis (Grade C). In women whose symptoms do not improve during therapy and in 

those whose symptoms recur after treatment, a repeat urine culture and sensitivity test should be 

performed (Grade C). 

6. Re-treatment 

Recurrence of symptoms requires antibiotic treatment based on results of urine culture and 

sensitivity test, in addition to assessment for underlying genito-urologic abnormality (Grade C). 

<strong>The</strong> duration of re-treatment in the absence of a urologic abnormality is 2 weeks (Grade C). For 

those patients who relapse with the same strain as the initially infecting strain, a 4-6 week 

regimen is recommended (Grade C).

III. ASYMYPTOMATIC BACTERIURIA 


Asymptomatic bacteriuria (ASB) is defined clinically by: (a) the presence of > 100,000 

cfu/ml of one or more uropathogens on two consecutive midstream urine specimens or on one 

catheterized urine specimen; and (b) the absence of symptoms attributable to urinary tract 

infection. 

<strong>The</strong> risk groups most likely to have asymptomatic bacteriuria are: (1) the elderly 

population, especially women; (2) women with diabetes mellitus; (3) individuals with long-term 

indwelling catheters; (4) patients with genitourinary abnormalities; and (5) renal transplant 

recipients (Grade B). <strong>The</strong> risk of asymptomatic bacteriuria among pregnant women is discussed 

in Section IV. Infections in renal transplant recipients are discussed in Section VI. 

2. Screening for asymptomatic bacteriuria 

Periodic testing for asymptomatic bacteriuria and treatment with antimicrobials is not 

recommended in the elderly (Grade D), in individuals with indwelling catheters (Grade E), 

immunocompromised patients (Grade C) and in patients with urological abnormalities (Grade C). 

Screening by urine culture is recommended in the following patients with diabetes 

mellitus, patients who will undergo genitourinary manipulation or instrumentation, and after 

catheter removal (Grade C). <strong>The</strong> frequency of screening is left to the discretion of the clinician 

(Grade C). 

In the absence of urine culture facilities, significant pyuria (> 10 wbc/hpf or a positive 

gram stain of unspun urine (2 microorganisms/oif) in 2 consecutive midstream urine samples can 

he used to screen for asymptomatic bacteriuria (Grade C). Urine culture and sensitivity testing are 

not necessary when urinalysis or gram stain of urine is normal (Grade C). 

It should be noted that pyuria is not an accurate screening test for bacteriuria in patients 

with poor inflammatory response, e.g. immunosuppressed renal transplant recipients, or patients 

with diabetic nephropathy and azotemia. 

3. Treatment of asymptomatic bacteriuria 

Treatment of asymptomatic bacteriuria may he considered in the following patients: (a) 

persistent bacteriuria after catheter removal (Grade B); (b) patients who will undergo 

genitourinary manipulation or instrumentation; (c) diabetic patients; and (d) patients with 

abnormal genitourinary tract (Grade C). (See Section VI for treatment regimens). 

For asymptomatic funguria, removal of predisposing factors, such as urinary catheters or 

prolonged antibiotic use will generally result in spontaneous resolution (Grade C). Treatment is 

not recommended in the following groups: (a) patients with long-term indwelling catheters 

(Grade E); (b) ambulatory elderly men and women (Grade D); and (c) patients with short-term 

indwelling catheters (Grade C). 

IV. URINARY TRACT INFECTION IN PREGNANCY 

A. ASYMPTOMATIC BACTERIURIA (ASB) IN PREGNANCY 

1. Definition

Asymptomatic bacteriuria in pregnancy is defined clinically by: (a) >100,000 cfu/ml with 

one or more organisms in two consecutive mid-stream urine specimens or one catheterized urine 

specimen, and (b) the absence of symptoms attributable to urinary infection. 

2. Screening for asymptomatic bacteriuria in pregnancy 

All pregnant women, particularly those at high risk of developing acute cystitis and acute 

pyelonephritis, e.g. diabetics and those with a previous history of UTI, must be screened for 

asymptomatic bacteriuria on their first prenatal visit (Grade A). 

2.2 A standard urine culture using a clean catch midstream urine is the test of choice in screening 

for asymptomatic bacteriuria (Grade A). In areas where urine culture facilities are not available, a 

urine gram stain is an acceptable substitute (Grade C). Leukocyte esterase and nitrite tests are not 

recommended for screening for ASB (Grade E). Urinalysis alone is not recommended for 

screening (Grade C). 

3. Treatment of asymptomatic bacteriuria in pregnancy 

3.1 Antibiotic treatment for asymptomatic bacteriuria is indicated to reduce the risk of acute 

cystitis and pyelonephritis in pregnancy as well as reduce the risk of LBW neonates and preterm 

infants (Grade A). 

3.2 It is recommended that antibiotic treatment he initiated upon diagnosis of ASB in pregnancy. 

Among the drugs, which can be used, are nitrofurantoin, amoxicillin, cephalexin, co-amoxiclav 

and TMP/-SMX (not in 3rd trimester) (Grade C). A 7-day course is recommended (Grade C). A 

follow-up culture should be done one week after completing the course of therapy (Grade C). 

B. ACUTE CYSTITIS IN PREGNANCY 


Acute cystitis is characterized by urinary frequency and urgency, dysuria and bacteriuria 

but not by fever and costovertebral angle tenderness. Gross hematuria may also be present (Harris 

1984). In the absence of a urine culture, the laboratory diagnosis of acute cystitis can he 

determined by the presence of significant pyuria defined as: (a) 8 or more pus cells/mm 3 of 

uncentrifuged urine OR, (b) 5 or more pus cells/hpf of centrifuged urine, and (c) positive 

leukocyte esterase and nitrate test (Grade C). 

2. Treatment 

Treatment of acute cystitis in pregnancy should be instituted immediately to prevent the 

spread of the infection ascending to the kidney (Grade A). Since E. coli remains to be the most 

common organism isolated drugs to which this organism is most sensitive and which are safe to 

give during pregnancy should he used (Grade A). A 7-day course is recommended (Grade C). 

C. ACUTE PYELONEPHRITIS IN PREGNANCY 


Acute pyelonephritis, an inflammation of the renal parenchyma, is characterized by 

shaking chills, fever (> 38 o C), flank pain, nausea and vomiting, with or without signs and

symptoms of lower urinary tract infection (frequency, urgency, dysuria and hematuria) and 

physical findings of costovertebral angle tenderness. Urinalysis shows pyuria of > 5 wbc/hpf of 

centrifuged urine and bacteriuria of >10,000 cfu of an uropathogen/ml of urine (Rubin 1992, 

Robert 1986, Harris 1984). 

2. Etiologic diagnosis 

2.1 Gram stain of uncentrifuged urine is recommended to differentiate gram positive from gramnegative 

bacteriuria, the result of which can guide choice of empiric therapy (Grade C). 

Quantitative urine culture and sensitivity test should also be performed routinely to allow for 

more precise and cost-effective use of antimicrobial agents and because of the potential for 

serious sequelae if an inappropriate antimicrobial regimen is used (Grade C). 

2.2 Blood cultures (done twice) are recommended for all pregnant patients with acute 

pyelonephritis (Grade C). 

3. Treatment 

3.1 All pregnant patients with acute pyelonephritis should be hospitalized and immediate 

antimicrobial therapy instituted (Grade A). Treatment duration is 14 days (Grade C). Choice of 

antibiotics is as for acute uncomplicated pyelonephritis except for drug’s contraindicated in 

pregnancy (see Table 4) (Grade C). 

3.2 For pregnant patients with no signs and symptoms of sepsis and are able to take medications 

by mouth, oral antibiotics may he given as first line drugs (grade A). Empiric choice should be 

based on local susceptibility patterns of uropathogens (Grade C). 

Table 4. Antibiotic use in pregnancy 

Safe Use with caution Contraindicated 

Cephalosporins Aminoglycoside Tetracycline 

Co-amoxiclav TMP/SMX (1st & 2nd trimester) Fluoroquinolone 

Ampicillin-sulbactam TMP/SMX (3rd) trimester 

Aztreonam (probably) 

(Reese and Betts 1996) 

V. RECURRENT URINARY TRACT INFECTION 


Recurrent UTI is defined as episodes of acute uncomplicated UTI documented by urine 

culture occurring more than twice a year in a non-pregnant woman with no known urinary tract 

abnormalities (Kraft 1977, Stamm 1980). 

2. Treatment of individual episodes 

Seven-day treatment with amoxicillin-clavulanate, Cephradine, ciprofloxacin and 

lomefloxacin is effective (Grade A). Three-day treatment with any of the antibiotics for simple 

uncomplicated cystitis (see Section 1) may be an acceptable alternative (Grade C). Intermittent 

self-administered therapy, wherein the patients are apprised of the common signs and symptoms 

of UTI and instructed to take four tablets of TMP/SMX (40 mg/200 mg) single dose as soon as

symptoms first appear, may be recommended in well-instructed and highly educated patients 

(Grade A). 

3. Prophylaxis 

3.1 Indication for prophylaxis. Prophylaxis is recommended in women whose frequency of 

recurrence is not acceptable to the patient in terms of level of discomfort or interference with her 

normal activities. Prophylaxis may be withheld according to patient preference if the frequency of 

recurrence is tolerable to the patient (Grade C). 

3.2 Prophylactic strategy. If prophylaxis is to be given, either of the following regimens is 

recommended: (1) continuous prophylaxis, defined as the daily intake of a low dose of antiantibiotic, 

or 2) post-coital prophylaxis, defined as the intake of a single dose of antibiotic 

immediately after sexual intercourse (Grade A). 

3.3 Choice and dose of antibiotic. A number of antibiotics given continuously for 6 months have 

been proven to effectively reduce the number of episodes of UTI (See Table 5) (Grade A). Postcoital 

prophylaxis with a number of antibiotics has also been proven to be effective (see Table 5) 

(Grade A). 

Table 5. Antibiotics which have been proven to be effective in reducing the number of recurrences of UTI and 

their recommended doses and regimens 

Recommended dose for continuous prophylaxis Recommended Dose for post-coital prophylaxis 

Nitrofurantoin 100 mg at bedtime 

Norfloxacin 200 mg at bedtime 200 mg 

TMP/SMX 40 mg/200 mg at bedtime 40 mg/200 mg 

Ciprofloxacin 125 mg at bedtime 125 mg 

Ofloxacin 100 mg 

References: Pfau 1994, Stapleton 1990, Brumfitt 1991, Brumfitt 1995, Stamey 1977, Stamm 1980, Nicolle 1989, 

Melekos 1997 

3.4 Duration of prophylaxis. Six-month continuous or post-coital prophylaxis effectively reduces 

the number of UTI episodes (Grade A). 

3.5 Treatment of breakthrough infections during prophylaxis. Breakthrough infections during 

prophylaxis should he initially treated with any of the antibiotics recommended for 

uncomplicated cystitis other than the antibiotic being given for prophylaxis (Grade B). A urine 

culture should he requested and the treatment modified accordingly. 

4. Diagnostic work-up for urologic abnormalities. 

4.1 Indication for screening. Screening is not recommended for all patients (Grade E). Certain 

risk factors associated with a higher incidence of urologic abnormalities have been identified. 

Screening is recommended for patients with: (1) gross hematuria during a UTI episode; (2) 

obstructive symptoms; (3) clinical impression of persistent infection; (4) infection with ureasplitting 

bacteria; (5) history of pyelonephritis; (6) history of or symptoms suggestive of 

urolithiasis; (7), history of childhood UTI; and (8) elevated serum creatinine (Grade C). 

4.2 Choice of screening procedure. A combination of a renal ultrasound and a plain abdominal 

radiograph is recommended (Grade B). Patients with anatomical abnormalities should he referred 

to a specialist (nephrologist or urologist) for further evaluation (Grade C).

5. Prophylaxis in post-menopausal women 

Use of estriol. In post-menopausal women, application of intra-vaginal estriol cream applied 

once each night for two weeks followed by twice-weekly applications for 8 months is 

recommended (Grade A). 

VI. COMPLICATED URINARY TRACT INFECTION 


Complicated UTI is significant bacteriuria, which occurs in the setting of functional or 

anatomic abnormalities of the urinary tract or kidneys. <strong>The</strong> conditions that define complicated 

UTI include the following (Rubin 1992): (a) the presence of an indwelling urinary catheter or use 

of intermittent catheterization; (b) incomplete emptying of the bladder with more than 100 ml of 

urine retained postvoiding; (c) obstructive uropathy due to obstruction of the bladder outlet, a 

calculus or other causes; (d) vesicoureteral reflux or other forms of urologic abnormalities 

including surgically created abnormalities; (e) azotemia due to intrinsic renal disease; and (f) 

renal transplantation. 

Other authors (Ronald & Harding 1997, Williams 1996, Stamm and Hooton 1993, Nickel 

1990) have broadened the definition to include UTI in patients with metabolic, hormonal or 

immunologic abnormalities, such as diabetes, impaired host responses and UTI caused by 

pathogens, which are either unusual or resistant to antibiotics. In addition, UTI in males is 

generally considered complicated except in young males presenting exclusively with 

symptomatic lower UTI (see Section VII.1.1). 

<strong>The</strong> cut-off for significant bacteriuria in complicated UTI has been set at 100,000 cfu/ml 

(Rubin 1992). However in certain clinical situations, low-level bacteriuria or counts

Table 6. Pathogens identified in complicated UTI 

Type of Complicated UTI Pathogens Reference 

Catheter-associated UTI 

Short-term (1 week) Proteus mirabilis, Enterobacter 

Usually polymicrobial, E. Coli, P. aeruginosa, P. mirabilis, 

Providencia stuartii, Morganella morgagnii, Citrobacter, 

Enterococcus, Candida sp. 

Anatomic abnormalities E. coli, Klebsiella pneumoniae (37%.), P. aeruginosa, Proteus 

mirabilis 

UTI in Diabetics E. coli, Klebsiella pneumoniae, Proteus mirabilis, Enterobacter, 

Enterococcus, P. aeruginosa, Candida sp. 

Renal Transplant Recipients E. coil (29-61%), Proteus mirabilis and Klebsiella pneumoniae 

(30%), Gram positive cocci (20%), Enterobacter, Enterococci, 

Serratia, Acinetobacter, Citrobacter, Pseudomonas aeruginosa 

Neutropenic Patients Gram negative bacilli spec. Pseudomonas aeruginosa, 

Staphylococcus aureus, Candida 

UTI in AIDS E. coli Enterobacter, Klebsiella pneumoniae, Pseudomonas, 

Enterococci, Staphylococcus aureus, Cytomegalovirus, 

Adenovirus, Toxoplasma, Pneumocystis carinii, 

Blastomyces dermatidis, Mycobacterium tuberculosis 

Table 7. Antimicrobial regimens that may be used as empiric therapy for complicated UTI 

Ouslander 

1987 

Childs 1993 

Patterson and 

Andriole 

1997 

Schmaldienst 

and Horl 1997 

Korzeniowski 

1991 

Sharifi and 

Lee 1997 

Antibiotic Regimen 

Oral Regimen Parenteral Regimen 

Ciprofloxacin 250 mg po q 12 hrs x 14 days Ampicillin 1 gm q 6hrs IV + gentamicin 3 mg/kg/day OD IV 

Norfloxacin 400 mg BID po x 14 days 

Ceftazidime 1-2 gm q 8hrs IV 

Ofloxacin 200 mg q 12hrs po x 14 days 

Ceftriaxone 1-2 gm OD IV 

Trimethoprim-sulfamethoxazole 160/800 q 12hrs po Ciprofloxacin 200-400 mg q 12hrs IV 

x 10 days 

Imipenem-cilastatin 250-500 mg q 6-8 hrs IV 

Ofloxacin 200-400 mg q 12hrs IV 

2.5 Further work-up to identify and correct the anatomical, functional or metabolic abnormality is 

indicated. Referral to the appropriate specialists, such as infectious diseases, nephrology or 

urology should be made as necessary (Grade C). 

2.6 Urine culture should he repeated one to two weeks after completion of medications (Grade 

C). Significant bacteriuria post-treatment needs appropriate referral (Grade C). 

3. Special issues 

3.1 Catheter-associated UTI. Catheterized patients with significant bacteriuria of > 100 cfu/ml of 

urine, who develop fever or other signs of bacteremia should be treated as complicated UTI 

(Grade B). Catheterized patients with no risk factors who are otherwise asymptomatic need not he 

treated with antibiotics (Grade E). Whenever possible, the indwelling catheter should be removed 

to help eradicate the bacteriuria (Grade A). 

3.2 Patients with diabetes. Acute uncomplicated cystitis in diabetic patients requires pre- 

treatment urine gram stain and culture and a post-treatment urine culture. At least 7-14 days of 

oral antibiotics is recommended (Grade C).

Diabetic patients who present with UTI and signs of sepsis should be hospitalized. 

Failure to respond to appropriate therapy within 48 to 72 hours warrants a plain abdominal 

radiograph and a renal ultrasound (Grade C). 

3.3. Renal transplant patients. UTI, which develop in the first three months post-operatively, as 

well as other UTIs which develop later with signs of pyelonephritis or sepsis, should be treated 

with parenteral broad-spectrum antibiotics until the urine cultures become negative. <strong>The</strong>rapy can 

he switched to oral agents according to the culture and sensitivity results and continued to 

complete 4-6 weeks (Grade C). 

Renal transplant patients who develop UTI within the first three months post-transplant 

with no evidence of sepsis may be treated as outpatients with oral antibiotics for more than 14 

days (Grade C). 

For renal transplant patients, prophylaxis with TMP/SMX (160/ 1800 mg) twice daily 

during the hospitalization period immediately post-surgery, then once daily upon discharge is 

recommended (Grade A). <strong>The</strong> actual dose of TMP/SMX should be adjusted to the renal function. 

Duration of prophylaxis should be given for 3 months (Grade C). 

3.4 Patients with acquired immunodeficiency syndrome (AIDS). In addition to the general 

management of complicated UTI, patients with AIDS and UTI should be evaluated to include 

other non-bacterial pathogens if clinically suspected and should be referred to an appropriate 

specialist (Grade C). 

VII. URINARY TRACT INFECTION IN MALES 

A. UNCOMPLICATED UTI IN YOUNG MALES 


Urinary tract infection in males is generally considered complicated. However, the first 

episode of symptomatic lower urinary tract infection occurring in a young (15-40 years old) 

otherwise healthy sexually active male with no clinical or historical evidence of a structural or 

functional urologic abnormality is considered as uncomplicated UTI. 

2. Diagnosis 

Significant pyuria in men is defined as > 10 wbc/mm 3 or 5 wbc/hpf in a clean catch 

midstream urine specimen. This shows good correlation with bladder bacteriuria and the growth 

of > 1000 colonies of one predominant species/ ml of urine and best differentiate sterile from 

infected bladder urine (Grade C). 

3. Recommended diagnostic work-up 

<strong>The</strong> recommended diagnostic work-up includes a urinalysis and urine culture (Grade C). 

Routine urologic evaluation and use of imaging procedures are not recommended (Grade C). 

4. Treatment 

TMP/SMX or a fluoroquinolone given for seven days is recommended (Grade C). 

Ampicillin, sulfonamides, tetracyclines and cephalothin are not recommended because of 

increasing resistance (Grade C). Choice of antibiotics should he guided by the prevailing 

resistance and sensitivity patterns in the community (Grade C).

B. PROSTATITIS* 

(*Note: Current clinical practice guidelines include only acute and chronic bacterial prostatitis and not non-bacterial 

prostatitis and prostatodynia syndromes. 

*In 1995, the National Institutes of Health Consensus Conference on Prostatitis proposed the following classification 

of prostatitis syndromes: Category 1, Acute Bacterial Prostatitis; Category 2, Chronic Bacterial Prostatitis; 

Category 3, Chronic Pelvic Pain Syndromes; a. Inflammatory b. Non-inflammatory and Category 4, Asymptomatic 

Prostatitis) 


1.1 Acute bacterial prostatitis. Acute prostate is defined as a febrile illness with abrupt onset 

marked by chills, low back and perineal pain, generalized malaise and prostration. Irritative 

voiding symptoms including dysuria, urgency, frequency and nocturia are characteristic. Rectal 

examination reveals a markedly tender prostate that is swollen, firm and warm. 

1.2. Chronic bacterial prostatitis. 

Chronic bacterial prostatitis is a more subtle illness than acute prostatitis typified by 

relapsing or recurrent UTI caused by persistence of the pathogen in the prostate despite courses of 

antibacterial therapy. Symptoms consist of varying degrees of irritative voiding and pain 

perceived in various sites - suprapubic, perineal, low back, scrotal, penile or even the inner thighs. 

Rectal examination discloses no specific or characteristic finding. 

1.3. Diagnosis. In chronic bacterial prostatitis, direct microscopic examination of the expressed 

prostatic secretions (EPS) identifies significant prostatic inflammation at > 10 wbc/hpf. <strong>The</strong> 

presence of lipid-laden macrophages is more prostate specific and strengthens the diagnosis. 

Diagnosis can be further confirmed by doing the triple voided urine test. In this 

examination, prostatitis can only be diagnosed if the specimen is free of WBC. <strong>The</strong> diagnosis of 

prostatic infection is confirmed when the quantitative bacterial colony counts of EPS and the next 

5 to 10 ml of urine (VB3) significantly exceed those of the urethral (VBI) and bladder (VB2) 

specimens. <strong>The</strong> colony count of the EPS and VB3 should exceed the VBI by at least 1 logarithm 

(Grade C). 

2. Treatment 

2.1 For acute prostatitis, empiric treatment with TMP/SMX (160/ 800 mg) or an oral 

fluoroquinolone may be started until culture and sensitivity results are known. <strong>The</strong> course of 

treatment should extend to at least 30 days to help prevent the development of chronic prostatitis 

(Grade C). Seriously ill patients require hospitalization and parenteral antimicrobial therapy, such 

as an aminoglycoside-penicillin derivative combination or fluoroquinolones (Grade C). When 

complications of urinary retention or the development of a prostatic abscess occurs, referral to an 

urologist is strongly recommended (Grade C). 

2.2 For chronic bacterial prostatitis, TMP/SMX or fluoroquinolones are indicated for two to three 

months (Grade C). 

2.3 Men with recalcitrant chronic bacterial prostatitis can be treated with radical transurethral 

resection of the prostate. Symptomatic relief can he achieved with Sitz baths, anti-inflammatory 

agents and prostatic massage and other supportive measures (Grade C).

Long-term, low-dose suppressive therapy may he required for patients who do not 

respond to full dose treatment. TMP/SMX 80mg /400mg once daily is recommended (Grade C). 

VIII. PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT 

INFECTION 

1. Personnel 

1.1 Only persons trained in correct aseptic techniques of catheter insertion and care should handle 

urinary catheters (Grade B). 

1.2. Hand washing should be done immediately before and after catheter insertion or care (Grade 

C). 

2. <strong>The</strong> catheter 

2.1. Avoid unnecessary catheter use (Grade C). 

2.2. Limit catheter use to carefully selected patients (Grade C). Routine catheterization during 

labor or immediately post-partum for collection of urine sample is not recommended (Grade C). 

2.3. Catheters should be inserted using aseptic technique and sterile equipment (Grade A). 

2.4. Maintain a sterile, closed catheter system at all times. Open drainage is unacceptable (Grade 

D). 

2.5. Urine specimens should he obtained aseptically without opening the catheter-collection 

junction (Grade B). 

2.6. Maintain unobstructed and adequate urine flow at all times (Grade B). 

2.7 Do not change catheters at arbitrary fixed intervals (Grade C). 

2.8 Remove the urinary catheter as soon as possible (Grade A). 

3. Methods to prevent endogenous infection 

3.1 Daily meatal care is not recommended (Grade E). 

4. Methods to prevent exogenous infection 

4.1 Irrigation of the bladder with antimicrobial agents is not useful (Grade D) 

4.2 Instillation of disinfectants into the bag and the use of antireflux valves and vents are not 

helpful. 

4.3 Segregate infected from uninfected catheterized patients (Grade C). 

5. Bacteriologic monitoring and treatment of asymptomatic bacteriuria to prevent complications 

(Secondary prevention).

5.1 Regular bacteriologic monitoring of catheterized patients is not recommended (Grade D). 

5.2 Use of systemic antibiotic prophylaxis in catheterized patients is discouraged (Grade C). 

5.3 Patients at high-risk for complications of catheter-associated bacteriuria, such renal transplant 

and granulocytopenic patients may benefit from antibiotic prophylaxis (Grade B). 

REFERENCES 

Abrutyn E, Mossey J, Berlin JA, Boscia J, Levison M, Pitsakis P, Kaye D. 1994. Does asymptomatic bacteriuria predict mortality and 

does antimicrobial treatment mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women. Ann 

Intern Med 120:827-833. 

Abyad A. 1991. Screening for asymptomatic bacteriuria in pregnancy: urinalysis vs. urine culture. J Family <strong>Practice</strong> 33:471-474. 

Adelson MD, Graves WL, Osborne NG. 1992. Treatment of urinary infections in pregnancy using single versus 10-day dosing 

[abstract]. J Natl Med Assoc 84:73-75. 

Alejandria MM, Manapat BD. 1998. Three-day versus conventional antibiotic regimen for uncomplicated urinary tract infections in 

women: a meta-analysis of randomized trials. PJMID 27:41-48. 

Andriole VT, Patterson TF. 1991. Epidemiology, natural history and management of urinary tract infections in pregnancy. Med Clin 

North Am 75:359-373. 

Andriole VT. 1975. Hospital acquired urinary tract infection and the indwelling catheter. 1975. 

Urol Clin North Am 2:451-469. 

Angel JL, O’Brien WF, Finas MA, Morales WJ, Lake M, Knuppel RA. 1990. Acute pyelonephritis in pregnancy: a prospective study 

on oral versus intravenous antibiotic therapy. Obstet Gynecol 76:28-32. 

Aslaksen A. 1990. Intravenous urography vs. ultrasonography in the evaluation of women with recurrent urinary tract infection. Scand 

J of Primary Health Care 8:85-9. 

Bachman JW, Heise RH, Naessons JM, Timmerman MG. 1993. A study of various tests to detect asymptomatic urinary tract 

infections in an obstetric population. JAMA 270:1971-1974. 

Bailey RR. 1994. Duration of antimicrobial treatment and the use of drug combinations for the treatment of uncomplicated acute 

pyelonephritis. Infection 22 Suppl 1:S50-52. 

Bailey RR. 1992. Quinolones in the treatment of uncomplicated urinary tract infections. Int J Antimicrobial Agents 2:19-28. 

Bailey RR, Lynn KL, Robson RA, Peddie BA, Smith A. 1992. Comparison of ciprofloxacin with netilmicin for the treatment of acute 

pyelonephritis. NZ Med J 105:102-103. 

Bailey RR, Lynn KL, Robson RA, Peddie BA, Smith A. 1986. Comparison of netilmicin with ceftriaxonefor the treatment of severe or 

complicated urinary tract infections. NZ Med J 99:459-461. 

Bailey RR, Peddie BA. 1987. Treatment of acute urinary tract infection in women. Ann Intern Med 107:430. 

Barlett RC, Galen RS. 1983. Predictive value of urine culture. Am J Clin Pathol.79:756-757. 

Bastable JR, Peel RN, Birch DM, Richards B. 1977. Continuous irrigation of the bladder after prostatectomy: Its effect on postprostatectomy 

infection [abstract]. Br J Urol 49:689-693. 

Belitsky P, Lannon SG, McDonald AS, Cohen AD, Marie TJ, Houlihan P, Whalen A. 1982. Urinary tract infections after kidney 

transplantation. Transplant Proc 14:696-699. 

Bergeron MG. 1979. Treatment of pyelonephritis in adults. Med Clin North Am 79:619-649. 

Boerama JBJ, Domen WBM, Branolte JH. 1985. Comparative efficacy and safety of ciprofloxacin and co-trimoxazole in the treatment 

of patients with complicated urinary tract infections [abstract]. Proceeding of the 14 th International Congress of Chemotherapy. 

Kyoto, Japan. S50-7. 

Bronsema DA, Adams JR, Pallares R, Wenzel RP. 1993. Secular trends in rates and etiology of nosocomial urinary tract infections in 

women. QJ Med. 81:811-20. 

Brumfitt W. 1991 Comparative trial of norfloxacin and macrocrystalline nitrofurantion in the prophylaxis of recurrent urinary tract 

infections in women. QJ Med 81:811-20. 

Brumfitt W. 1990 Comparative study of cephradine and amoxicillin-clavulanate in the treatment of recurrent urinary tract infections. 

Antimicrob Agents Chemother 34:1803-1805. 

Brumfitt W. 1995. A comparative trial of low dose cefaclor and macroxyrstalline nitrofurantion in the prevention of recurrent urinary 

tract infection. Infection 23:98-102. 

Burke JP, Garibaldi RA. Britt MR, Jacobson JA. Conti M, Alling DW. 1981. Prevention of catheter associated urinary tract infections. 

Efficacy of daily meatal care regimens. Am J Med 70:655-658. 

Burke JP, Jacobson JA, Garibaldi RA, Conti MT, Alling DW. 1983. Evaluation of daily meatal care with poly-antibiotic ointment in 

prevention of urinary catheter-associated bacteriuria [abstract]. J Urol 129:331-334. 

Calderon JE, Arredondo GJL, Olvera SJ, Echaniz AG, Conde GC, Hernandez NP. 1989. Acute urethritis during pregnancy [abstract]. 

Gynecol Obstet Max 57:57-63. 

Carlos CC. 1997. Antimicrobial resistance surveillance program progress report. 

Carlson KJ, Mulley AG. 1985. Management of acute dysuria. A decision-analysis model of alternative strategies. Ann Intern Med 

102:244-249. 

Classen DC, Larsen RA, Burke JP, Allin DW, Stevens LE. 1991. Daily meatal care for prevention of catheter-associated bacteriuria: 

Results using frequent applications of polyantibiotic cream [abstract]. Infect Control Hosp Epidemiol 12:57-162. 

Cox CE. 1992. A comparison of the safety and efficacy of lomefloxacin and ciprofloxacin in the treatment of complicated or recurrent 

urinary tract infections. Am J Med 92 Suppl n4A:835-86S. 

Cox CE. 1980. Ofloxacin in the management of complicated UTI including prostatitis. Am J Med Suppl 6C:61. 

Cunningham FG, Morris GE, et al. 1975. Acute pyelonephritis of pregnancy: A clinical review. Obstet Cynecol 12:112.

Cuvelier R, Pirson Y, Alexandre GRJ, van Ypersele de Strihou C. 1985. Late urinary tract infection after transplantation: Prevalence, 

predisposition and morbidity. Nephron 40:76-78. 

Daifuki R, Stamm WE. 1984. Association of rectal and urethral colonization with urinary tract infection in patients with indwelling 

catheters. JAMA 252:2028-2030. 

Davies AJ, Desai HN, Turton S, Dyas A. 1987. Does instillation of chlorhexidine into the bladder of catherized geriatric patients help 

reduce bacteriuria. J Hosp Infect 9:72-75. 

De Guzman V, Nicolas C, Naidas O. 1998. Efficacy of single dose versus three days of antibiotics for uncomplicated urinary tract 

infection: A meta-analysis of randomized trials. In press. 

Dytan AT, Chua JA. 1998. Study of uncomplicated urinary tract infection [abstract] PJMID 27:S15. 

Epstein SE. 1985. Cost-effective application of the Centers for Disease Control <strong>Guideline</strong> for Prevention of catheter-associated urinary 

tract infections [abstract]. Am Infect Control 13:272-275. 

Fairchild TN 1982. Radiographic studies for women with recurrent urinary tract infections. J Urol 128:344-345. 

Fletcher RH, Fletcher SW, Wagner EH. 1996 <strong>Clinical</strong> Epidemiology: <strong>The</strong> Essentials. Baltimore: Williams & Wilkins. 

Forland M. 1993. Urinary tract infection: How has its management changed? Post Grad Med 93:71-86. 

Forland M, Thomas V, Shelokov A. 1997. Urinary tract infections in patients with diabetes mellitus: Studies on antibody coating of 

bacteria. JAMA 238:1924-1926. 

Fox BC, Sollinger HW, Belzer FO, Maki DG. 1990. Prospective randomized double-blind study of trimethoprim-sulfamethoxazole for 

prophylaxis of infection in renal transplantation: <strong>Clinical</strong> efficacy, absorption of trimethoprin-sulfa-methoxazole, effects on the 

microflora and the cost-benefit of prophylaxis. Am J Med 89:255-274. 

Fox CE, Tack KJ. 1988. Safety and efficacy of ofloxacin vs. trimethoprim-sulfamethoxazole for complicated urinary tract infections. 

Rev Infect Dis 10 Suppl 1:S175. 

Garibaldi RA, Burke JP, Dickman ML, Smith CB. 1974. Factors predisposing to bacteriuria during indwelling urethral catheterization. 

N Eng J Med 291:215-219. 

Garibaldi RA, Burke JP, Britt MR, Miller WA, Smith CB. 1980. Meatal colonization and catheter associated bacteriuria. N Engl J 

Med 303:316-318. 

Gillespie WA, Simpson RA, Jones JE, Nashef L, Teasdale C, Speller DC. 1983. Does the addition of disinfectant to urine drainage 

bags prevent infection in catheterized patients? Lancet 1:1037-1039. 

Gilstrap LC III, Cunningham FG, Whalley PJ. 1981.Acute pyelonephritis in pregnancy: An anterospective study: Obstet Gynecol 

57:409-413. 

Golan A, Wexler S, Amit A, Gordon D, David M. 1989. Asymptomatic bacteriuria in normal and high risk pregnancy. Eur J Obstet 

Gyne Reproductive Biol 33:101-108. 

Guerra JG, Falconi E, Palomino JC, et al. 1983. <strong>Clinical</strong> evaluation of norfloxacin vs. cotrimoxazole in urinary tract infections. Eur J 

Clin Microbiol 2:260-265. 

Harding GKM, Nicolle LE, Ronald AR, Preiksaitis, JK Forward KR, Low DE, Cheang M. 1991. How long should catheter-acquired 

urinary tract infection in women be treated? A randomized controlled study. Ann Intern Med 114:713-719. 

Harris RE. 1979. <strong>The</strong> significance of eradication of bacteriuria during pregnancy. Obstet Gyne 53. 

Harris RE. 1984. Acute urinary tract infections and subsequent problems. Clin Obstet Gyne 27:8974-890. 

Harris RE, Gilstrap LG III. 1981. Cystitis during pregnancy: A distant clinical entity. Obstet Gyne 57:578. 

Harstein Al, Garber SB, Ward TT, Jones SR, Morthland VH. 1981. Nosocomial urinary tract infection: A prospective evaluation of 

108 catheterized patients [abstract]. Infect Control 2:380-386. 

Hill JA, Devoe LD, Bryans IC. 1986. Frequency of asymptomatic bacteriuria in pre-eclampsia. Obstet Gyne 67:529-532. 

Hooton TM, Stamm WE. 1997. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 11:551- 

581. 

Hooton TM, Winter C, Tiu F, Stamm WE. 1995. Randomized comparative trial and cost analysis of 3-day antimicrobial regiments for 

treatment of acute cystitis in women JAMA 273:1:41-5. 

Huth TS, Burke JP, Larsen RA, Classen DC, Stevens LE. 1992. Randomized trial of meatal care with silver sulfadiazine cream for the 

prevention of catheter-associated bacteriuria. J Infect Dis 165:148. 

Israel RS, Lowenstein SR, Marx JA, et al. 1991. Management of acute pyelonephritis in an emergency department observation unit. 

Ann Emerg Med 20:253-257. 

Jernelius H,. Zbornik J, Bauer CA. 1988. One or three weeks treatment of acute pyelonephritis? A double-blind comparison, using a 

fixed combination of pivampicillin plus pivmecillinam. Acta Medica Scand 223:469-477. 

Johnson JR, Lyons MF, Pearce W, et al 1991. <strong>The</strong>rapy for women hospitalized with acute pyelonephritis: a randomized trial of 

ampicillin vs trimethoprin-sulfamethoxazole for 14 days. J Infect Dis 163:325-330. 

Johnson JR, Vincent LM, Wang K, Roberts PL, Stamm WE. 1992. Renal ultrasonographic correlates of acute pyelonephritis. Clin 

Infect Dis 14:15-22. 

Kanel KT, Kroboth FJ, Schwentker FN, Lecky JW. 1983. <strong>The</strong> intravenous pyelogram in acute pyelonephritis. Arch Intern Med 

148:2144-2148. 

Kass EH. 1956. Asymptomatic infections of the urinary tract. Trans Assoc Am Phys 69:56-64. 

Keys TF, Maker MD, Segura JW. 1979. Bacteriuria during closed urinary drainage: an evaluation of top-vented versus bag-vented 

systems J Urol 122:49-51. 

Kim ED, Schaeffer AJ. 1994. Antimicrobial therapy for urinary tract infections. Seminars in Nephrology. 14:551-69. 

Komaroff AL. 1991. Acute dysuria in adult women. In: Panzer RJ, Black ER, Griner PF, editors Diagnostic strategies for common 

medical problems. Philadelphia: Am College of Physicians p 239. 

Korzeniowski OM. 1991. Urinary tract infection in the impaired host. Med Clin North am 75:391-404. 

Kraft JK. 1977. <strong>The</strong> natural history of symptomatic recurrent bacteriuria in women. Medicine 56:55-60. 

Kunin CM, Mc Cormack RC. 1966. Prevention of catheter-induced urinary tract infection by sterile closed drainage. N Engl J Med 

274:1155-1162. 

Kunin CM. 1992. Editorial guidelines for the evaluation of new anti-infective drugs for the treatment of urinary tract infections. Clin 

Infect Dis 15:1041-1044. 

Kunin CM. 1997. Detection, prevention and management of urinary tract infections. 5th ed. Philadelphia: Lea and Febiger.

Kunin C, White L, Hua Hua T. 1993. A re-assessment of the importance of ‘low count”bacteriuria in young women with acute urinary 

symptoms. Ann Intern Med 119:454-59. 

Lacks MS, Nacharin I, Edelstein P. 1992. Spectrum bias in the evaluation of diagnostic test. Lessons from rapid dipstick test for 

urinary tract infection. Ann Intern Med 117:135-40. 

Leibovici L, Wysenbeck. 1991. Single-dose antibiotic treatment for symptomatic urinary tract infection in women: A meta-analysis of 

randomized trials. J Med 285:43-57. 

Lenke RR, Van Dorsten JP, Schifrin BS. 1983. Pyelonephritis in pregnancy: a prospective randomized trial to prevent recurrent 

disease evaluating suppressive therapy with nitrofurantion and close surveillance [abstract]. J Obstet Gynecol 146:953-957. 

Lipsky BA, Ireton R, et al 1987. <strong>The</strong> diagnosis of bacteriuria in men: Specimen collection and culture interpretation J. Infect Dis 

155:847-54. 

Malinverni R, Glauser MP. 1988. Comparative studies of fluroquinolones in the treatment of urinary tract infections. Rev Infect Dis 

10 suppl 1:S153-163. 

McHenry MC, Braun WE., Popowniak KL, Banowsky H, Deodhar SD. 1976. Septicemia in renal transplant recipients. Urol Clin 

North Am 3:647-666. 

McNicholas MM. 1991. Ultrasound of the pelvis and renal tract combined with a plain film of abdomen in young women with urinary 

tract infection: can it replace intravenous urography? Br J Radiol 64:221-4. 

Meares EM Jr. 1980. Prostatitis syndromes. New perspectives about old woes. J Urol 123.141- 147. 

Melekos MD. 1997. Post-intercourse versus daily ciprofloxacin prophylaxis for recurrent urinary tract infections in premenopausal 

women. J J Urol 157:935-939. 

Mendoza MT, Liquete RR, Ona ET, Alano FA. 1997. Infections in renal allograft recipients: a review of the <strong>Philippine</strong> experience. Int 

J Infect Dis 1:222-225. 

Mittendorf R, Williams MA, Kass EH. 1992 Prevention of preterm delivery and low birth weight associated with asymptomatic 

bacteriuria. Clin Infect Dis 14:927-32. 

Mountokalakis T, Shounakis M, Tselentis J. 1985. Short-term versus prolonged systemic antibiotic prophylaxis in patients treated with 

indwelling catheters. J Urol 134:506-508. 

Mouton J, Ajana F, Chidiac C. et al. 1992. A multicenter study of lomefloxacin and trimethoprim-sulfamethoxazole in the treatment of 

uncomplicated acute pyelonephritis. Am J Med 92 suppl 4A:S87. 

Mushlin Al, Thorbury JR. 1989. Intravenous pyelography: the case against its routine use. Ann Intern Med 111:58-70. 

Myerowitz RL, Medeiros AA, O’Brien TF. 1972. Bacterial infection in renal homotransplant recipients: A study of fifty-three 

bacteremic episodes. Am J Med 53:308-314. 

Neu HG. 1992. Urinary tract infections. Am J Med 92 Suppl 4A:63S-70S. 

Nickel JC. 1990. Special considerations in the management of complicated urinary tract infections. International Congress and 

Symposium Series: Management of Urinary tract Infections. 85-95. 

Nicolle LE. 1997. Asymptomatic bacteriuria in the elderly. Infect Dis Clin North am 11:647-662. 

Nicolle LE, Mayhew JW, Bryan L. 1987 Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria 

in institutionalized women. Am J Med 83:27-33. 

Nicolle LE, Bjornson J, Harding GKM MacDonell JA. 1983. Bacteriuria in elderly institutionalized men. N Engl J Med 309:1420- 

1425. 

Nicolle LE. 1989. Prospective, randomized, placebo-controlled trial of norfloxacin for the prophylaxis of recurrent urinary tract 

infection in women. Antimirob Agents Chemother 33:1032-5. 

Norman DC, Yamamura R Yoshikawa TT. 1966. Pyuria: Its predictive value of asymptomatic bacteriuria in ambulatory elderly 

men J Urol 135:520-522. 

Norby SR 1994. Useful agents in the management of urinary tract infections. Int. J Antimicrob agents. 4:129-134. 

North DH, Speed JE, Weiner WB, Morrison JC. 1980. Correlation of urinary tract infection with urinary screening at the first 

antepartum visit. J MSMA: 331-333. 

Ouslander JG, Schapira M, Schnelle JF, et al. 1995. Does eradicating bacteriuria affect the severity of chronic urinary incontinence in 

nursing home residents? Ann Intern Med 122:749-754. 

Ouslander JG, Greengold B, Chen S. 1987. Complications of chronic indwelling urinary catheters among male nursing home patients: 

a prospective study J of Urol 138:1191-1195. 

Patterson JE, Andriole VT. 1997. Bacterial urinary tract infections in diabetes. Infect Dis North Am 7325:750. 

Pena AC, Mendoza MT, Go-Yap J. 1996. A randomized open-label tolerance and efficacy study of oral tosufloxacin vs. oral 

trimethoprin-sulfamethoxazole forte in the treatment of patients with complicated and uncomplicated urinary tract infections in 

the <strong>Philippine</strong>s. PJ IM 34:123-128. 

Peters HJ. 1986. Comparison of intravenous ciprofloxacin and mezlocillin in treatment of complicated urinary tract infection. Eur J 

Clin Microbiol 5:253-255. 

Pewitt EB, Schaeffer AJ. 1997. Urinary tract infection in urology, including acute and chronic prostatitis, Infect Dis Clin North Am 

11. 

Pfau A. 1994. Effective postcoital quinolone prophylaxis of recurrent urinary tract infections in women. J Urol 152:136-138. 

Pinson AG, Philbrick JT, Lindbeck GH, Schorling JB. 1992. J Gen Intern Med 7:544-553. 

Pinson AG, Philbrick JT, Lindbeck GH, Schorling JB. 1994 ED management of acute pyelonephritis in women: a cohort study. Am J 

Emerg Med 12:271-278. 

Pittmann W, Moon JO, Hamrick LC, Cox CE, Clark J. Childs Pizzutti D, Fredericks J, St. Clair P. 1993. randomized double-blind trial 

of high and low dose fleroxacin versus norfloxacin for complicated urinary tract infection. Am J Med 94 suppl 3A:101S-107S. 

Platt R. 1983. Quantitative definition of bacteriruria. Am J Med 75:44-52. 

Platt R, Murdock B, Polk BF, Rosner B. 1983 Reduction of mortality associated with nosocomial urinary tract infection. Lancer 

1:893-897. 

Power RD. 1991. New directions in the diagnosis and therapy of urinary tract infections. Am J Obstet Gynecol 164:1387-1389 

Raco MO, Barez MYC. 1998. Profile of community acquired urinary tract infections in Davao City PJMID 27:2:62-66 

Ramsey DE, Finch WT, Birtch AG. 1979 Urinary tract infection in kidney transplant recipients. Arch Surg 114:1022-1026.

Raz R, Stamm WE. 1993. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N 

Engl J Med 329:753-756. 

Reddy J, Campbell A. 1985. Bacteriuria in pregnancy. Aust & NZJ Obstet Gynecol 25:176-178. 

Reese RE, Betts RF, editors. 1997. Catheter-associated UTI. A Practical approach to infectious disease 4th ed. 12:506-511. 

Renoult E, Aouragh F, Mayeuz D, Hestin D, Lataste A, Hubert J, L’Hermite J, Kessler M. 1994. Factors influencing early urinary 

tract infections in kidney transpland recipients. Transplant Proc 26:2056-2058. 

Roberts FJ. 1986 Quantitative urine culture in patients with urinary tract infection and bacteremia. Am J Clin Pathol 85:616-618. 

Romero R, Oyarzun E, Mazor M, Sirtori M, Hobbins JC, Bracken M. 1989. Meta-analysis of the relationship between asymptomatic 

bacteriuria and preterm delivery/low-birth weight. Obstet gynecol 73:576-582. 

Ronald AR, Harding GK. 1997 complicated urinary tract infections. Infect Dis Clin North Am 11:583-592. 

Ronald AR, Pattullo ALS. 1991. <strong>The</strong> Natural History of Urinary infection in Adults. 75:299-312. 

Rose BD. 1997. Struvite stones. UptoDate Inc. 

Rubin RH, Bean TR, Stamm WE. 1992. An approach to evaluating antibacterial agents in the treatment of urinary tract infection. Clin 

Infect Dis 14 suppl 2:S246:251. 

Rubin RH, Fang LST, Cosimi, AB, Herrin JT, Varga PA, Russell PS, Tolkiff-Rubin NE. 1979. Usefuleness of the antibody-coated 

bacteria assay in the management of urinary tract infection in the renal transplant patient. Transplantation 27:18-20. 

Rubin RH, Shapiro ED, Andriole VT, Davis RJ, Stamm WE. 1992. General guidelines for the evaluation of new anti-infective drugs 

for the treatment of urinary infections. Clin Infect Dis 15 suppl 1:S216-27. 

Rubin RH, Beam TR Jr, Stamm WE. 1992. An approach to evaluating antibacterial agents in the treatment of urinary tract infection. 

Clin Infect Dis 14 Suppl 2;S246-251. 

Rubin RH Shapiro ED andriole VT et al 1992 evaluation of new anti-infective drugs for the treatment of urinary tract infection. Clin 

Infect Dis 15 Suppl 1:S216-27. 

Rubin RH, Wolfson JS, Cosimi AB, Tolkoff- Rubin NE. 1981. Infection in the renal transplant recipient. Am J Med 70:405-411. 

Sabbaj J, Hoagland VL, Shih WJ. 1985. Multiclinic comparative study of norfloxacin and timethoprim-sulfamethoxazole for treatment 

of urinary infections. Antimicrob Agents Chemother 27:297-301. 

Safrin S, Siegel D, Black D. 1988. Pyelonephritis in adult women: inpatient vs outpatient therapy. Am J Med 85:793-798. 

Sandberg T, Englund G. Lincoln, et al. 1990. Randomized double-blind study of norfloxacin and cefadroxil in the treatment of acute 

pyelonephritis. Eur J Clin Microbiol Infect Dis 9:317-323. 

Sanford J. 1964. Hospital acquired urinary tract infection. Ann Int Med 60:903-913. 

Schaberg DR, Haley RW, Highsmith AK, Anderson RL, Mcgowan JE. 1980. Nosocomial bacteriuria. A prospective study of case 

clustering and antimicrobial resistance. Ann Intern Med 93:420-424. 

Schmaldienst S, Horl WH. 1997. Bacterial infections after renal transplantation. Nephron 75: 140-153. 

Sharifi R, Lee M. 1997. Urinary tract infections in HIV infected men Infect. Urol 10:24-25. 

Smaill F. 1998 Antibiotic vs no treatment for symptomatic bacteriuria in pregnancy. Cochrane Review. <strong>The</strong> Cochrane Library (2):1- 

10. 

Spencer J, Lindsell D, Mastorakou L. 1990. Ultrasonography compared with intravenous urography in investigation of urinary tract 

infection in adults. BMJ 301:221-224. 

Stamey TA. 1977. Prophylactic efficacy of nitrofurantoin macrocrystals and trimethoprin-sulfamethoxazole in urinary infections: 

Biologic effects on the vaginal and rectal flora. N Engl J Med 296:780-783. 

Stamm WE, HootonTM. 1993. Management of urinary tract infection in adults. N Engl J Med 319:1328-1334.Stamm WE, Counts 

GW, Running KR, et al. 1982. Diagnosis of c`oliform infection in acutely dysuric women. N Engl J Med 307-463. 

Stamm WE. 1980. Antimicrobial prophylaxis of recurrent urinary tract infections: a double-blind, placebo-controlled trial. Ann Intern 

Med 92:770-5. 

Stamm WE, Mckevitt M, Counts GW. 1987. Acute renal infection in women: treatment with trimethoprim-sulfamethoxazole or 

ampicillin for two or six weeks; a randomized trial. Ann Intern Med 106:341-345. 

Stansfeld JM. 1962. <strong>The</strong> measurement and meaning of pyuria. Arch Dis Child 37:257-6. 

Stapleton A. 1990. Postcoital antimicrobial prophylaxis for recurrent urinary tract infection: a randomized double-blind, placebocontrolled 

trial. JAMA 264:703-6. 

Stark RP, Maki DG. 1984. Bacteriuria in the catheterized patient: What quantitative level of bacteriuria is relevant? N Engl J Med 

311:560-564. 

Steere AC, Mallison GF. 1975. Handwashing practices for the prevention of nosocomial infections. Ann Intern Med 83:683-90. 

Stenqvist K, Dahlen-Nilsson I, Lichin-Janson G. 1989. Bacteriuria in pregnancy. Am J Epidemiol 129:372. 

Stuby U, Kaise W, Grafinger P, Beisenbach, Zazgornik J. 1989. Urinary tract infection after renal transplantation under conventional 

therapy and cyclosporine. Transplant Proc 21:2110-2111. 

Sweet DE, Goodpasture HC, Holl K, Smart S, Alexander H, Hedari A. 1985. Evaluation of H202 prophylaxis of bacteriuria in patients 

with long-term indwelling foley catheters: a randomized controlled study [abstract]. Infect Control 6:263-266. 

Talan DA, Stamm WE, Reuning-Scherer J, Church D, and the Pyelonephritis Investigators Group. 1998. Ciprofloxacin 7 day vs TMP- 

SMX 14 day + ceftriaxone for acute uncomplicated pyelonephritis: A randomized, double-blind trial [abstract] 8th International 

Congress on Infectious Disease. Boston, Mass. 

Thompson RL, Haley CE, Seacy MA, Guenther SM, Kaise DL, Groschel DH, et al. 1984. Failure to reduce attack rates using periodic 

instillations of a disinfectant into urinary drainage systems. JAMA 251:747-751. 

Tincello D, Richmond DH. 1998. Evaluation of reagent strips in detecting asymptomatic bacteriuria in early pregnancy: Prospective 

case series. BMJ 316:435-437. 

Tulkoff-Rubin NE, Rubin RH. 1997. Urinary tract infection in the immunocompromised host: Lessons from kidney transplantation 

and the AIDS epidemic. Infect Dis Clin North Am 11:707-717. 

US Preventive Services Task Force. 1996. Guide to <strong>Clinical</strong> Preventive Services. Baltimore: William & Wilkins. 

VanDorsten P, Lenke RR, Schifrin GS. 1987. Pyelonephritis in pregnancy. <strong>The</strong> role of in-hospital management and nitrofurantion 

suppression. J Rep pregnant women. Am J Obstet Gynecol 155:777-780. Med 32:895-900.Dorsten PJ, Bannister ER. 1986. 

Office diagnosis of asymptomatic bacteriuria in Villar J, Lyndon-Rochelle MT, Gulmezoglo AM. 1998. Duration of treatment of 

asymptomatic bacteriuria during pregnancy. Cochrane Review. <strong>The</strong> Cochrane Library. (2).

Wadland, William C, Plante, Dennis A. 1989. Screening for asymptomatic bacteriuria in pregnancy: A decision and cost-analysis. J 

Family <strong>Practice</strong> 29:372-376. 

Walter S, Pedersen FB, Vejlsgaaed R. 1975. Urinary tract infection and wound infection in kidney transplant patients. Brit J Urol 

47:513-517. 

Ward G, Jorden RC, Severance HW. 1991. Treatment of pyelonephritis in an observation unit. Ann Emerg Med 20-:258-261. 

Warren JW. 1997. Catheter-associated urinary tract infections. Infect Dis Clin North Am 11:609-622. 

Warren JW, Anthony WC, Hoopes JM, Muncie HL. 1982. Cephalexin for susceptible bacteriuria in afebrile,.long-term catheterized 

patients. JAMA 248:454-458. 

Warren JW, Platt R, Thomas RJ, Rosner B, Kass EJ. 1978. Antibiotic irrigation and catheter-associated urinary tract infections. N 

Engl J Med 299:570-573. 

Warren JW. 1997 Catheter-associated urinary tract infections. Infect Dis Clinics North Am 11:609-622. 

Warren JW, Anthony WC, Hoopes JM, Muncie HL. 1982 Cephalexin for susceptible bacteriuria in afebrile long term catheterized 

patients. JAMA 248:454-458. 

Wilkie ME, Almond MK, Marsh FP. 1992. Diagnosis and management urinary tract infection in adults BMJ 305:1137-1141. 

Willinam DN. 1996. Urinary tract infection: emerging insights into appropriate management. PostGrad Med 99:189-201. 

Willie JC, Blusse van Oud Alblas A, <strong>The</strong>wessen EA. 1993. Nosocomial catheter-associated bacteriuria: a clinical trail comparing two 

closed urinary drainage systems [abstract]. J Hosp Infect 25:191-198. 

Winston DJ, Gale RP, Meyer DV, Young LS. 1979. Infectious complications of human bone marrow transplantation. Medicine 58:1- 

31. 

Wong ES. 1983. <strong>Guideline</strong>s for prevention of catheter-associated urinary tract infections. Am J Infect Control 11:28-36. 

Wong ES. 1985. Management of recurrent urinary tract infections with patients-administered single-dose therapy. Ann Intern Med 

102:302-7. 

Wong-Beringer A, Jacobs RA, Guglielmo J. 1992. Treatment of funguria. JAMA 267:2780-2785. 

Zhanel GG, Harding GKM, Guay DRP. 1990. Asymptomatic bacteriuria: which patients should be treated? Arch Intern Med 

150:1389-1397. 

Zhanel GG Harding GK Nicolle LE 1991. Asymptomatic bacteriuria in patients with diabetes mellitus. Rev Infect Dis 13:150-154. 

Zhanel GG, Harding GK, Nicolle LE. 1995. Prevalence of asymptomatic bacteriuria and associated host factors in women with 

diabetes mellitus. Clin Infect Dis 21:316-322. 

FIGURE A. Algorithm for UTI 

VIII. ALGORITHMS

FIGURE B: Algorithm for Acute Uncomplicated Cystitis 

FIGURE C. Algorithm for Acute Uncomplicated Pyelonephiritis

Categories reflecting the strength of recommendation 

Appendix 1 

Grading System for Recommendations 

GRADE DEFINITION 

A Good evidence to support a recommendation for use 

B Moderate evidence to support a recommendation for use 

C Poor evidence to support a recommendation for or against use 

D Moderate evidence to support a recommendation against use 

E Good evidence to support a recommendation against use 

Appendix 2 

Quality filters in assessing the evidence from the literature 

1. Studies on effectiveness of treatment and accuracy of diagnostic tests: Level of quality of evidence 

I Evidence from at least one properly randomized controlled trial. 

II Evidence from at least one well-designed clinical trial without randomization, from cohort or casecontrolled 

analytic studies (preferable from more than one center), from multiple time-series studies, or 

from dramatic results in uncontrolled experiments. 

III Evidence from opinions of respected authorities on the basis of clinical experience, descriptive studies, or 

reports of expert committees. 

2. Studies on prognosis or causation: Criteria for assessing quality of evidence 

A. An inception cohort was chosen. 

B. Reproducible and inclusion and exclusion criteria were used. 

C. Follow-up was complete for at least 80% of subjects. 

D. Statistical adjustment was carried out for confounders or extraneous factors. 

E. Reproducible descriptions of outcome measures were used. 

Level of Quality of Evidence: 

I. All of the criteria were satisfied. 

II. An inception cohort was selected but only 3 of 4 remaining criteria were satisfied. 

III. An inception cohort was selected but only 2 of 4 remaining criteria were satisfied. 

IV. An inception cohort was selected but only 1 of 4 remaining criteria was satisfied 

V. None of the 5 criteria was met. 

Appendix 3 

Laboratory criteria for significant pyuria and bacteriuria 

Strength of Cut-off for Strength of 

Syndrome 

Cut-off for pyuria* recommendation bacteriuria recommendation 

1. Acute uncomplicated a. ≥ 8 pus cells/ mm 

cystitis 

3 C 

≥ 100 cfu/ml 

A 

b. ≥ 5 pus cells/ hpf C 

≥ 1000 cfu/ml 

(clinical trials) 

C 

2. Acute uncomplicated 

pyelonephritis 

≥ 5 pus cells/hpf C ≥ 10,000 cfu/ml B 

3.Asymptomatic bacteriuria > 10 pus cells/ hpf C ≥ 100,000 cfu/ml A 

4. Complicated UTI ≥ 100,000 cfu/ml 

(with exceptions) C 

5. UTI in males a. ≥ 10 pus 

cells/mm 3 

C ≥ 1000 cfu/ml C 

b. ≥ 5 pus cells/ hpf C 

*Pus cell per mm 3 and per hpf refer to number found in uncentrifuged and centrifuged urine respectively.

Key points about urine collection: 

Appendix 4 

1. Clean-voided urine is recommended for adult females. 

2. No special preparation is needed to collect specimens from pre-pubertal females. 

3. No special preparation is needed for males, but the foreskin should be retracted. 

4. Urethral catheterization may be needed in adults who are suspected to have infection and cannot provide a clean – 

voided specimen. In such case, the laboratory should be informed that the specimen is catheterized urine. 

5. First void morning specimens yield the highest bacterial counts. In practice, the best time to collect is when patient 

is able to provide an adequate sample. 

6. Urine specimens should be delivered to the laboratory without delay and should be cultured within one hour after 

voiding or be refrigerated. 

Instructions to the adult female to collect a clean-voided specimen: 

1. Remove underpants completely so they will not get soiled. 

2. Sit backwards on the toilet seat. Swing knee to the side as far as you can. 

3. Spread your genitals with one hand, and continue to hold yourself spread while you clean and collect the specimen. 

4. Before you collect urine, clean between the folds of your genitals around the area from which you pass urine with 

soaped wash cloth, rinse the wash cloth with tap water, dry yourself with clean cloth and void into a clean jar with 

a screw-top lid. 

Adapted from Kunin CM 1997. Detection, Prevention And Management of Urinary Tract Infections 

Conditions that may be associated with sterile pyuria 

Appendix 5 

Contamination during collection Vaginal secretions Foreskin secretions 

Non-infectious causes of pyuria Vesicoureteral reflux Hypercalcemic 

nephropathy 

Allergic interstitial 

nephritis 

Analgesic nephropathy Lithium toxicity Sickle cell disease 

Uric acid nephropathy Hyperoxalosis Sarcoidoisis 

Polycystic kidney Heavy metal toxicity Idiopathic interstitial 

cystitis 

Acute tubular necrosis Carcinoma of bladder Glomerulonephritis 

Transplant rejection Renal calculi 

Infectious diseases Tuberculosis 

Chlamydial and 

Leptospirosis 

gonococcal urethritis 

Infections adjacent to the urinary tract Appendicitis Diverticulitis 

Appendix 6 

Cost of oral drugs commonly used for UTI 

Viral cystitis 

Drug/Regimen 3-day 7-day 14-day 

Co-trimoxazole Generic 160/800 mg q 12h PhP 66.00 PhP 154.00 PhP 308.00 

Nitrofurantoin 100 mg q 6 h 178.20 415.80 831.60 

Amoxicillin/Clavulanate 375 mg q 8 h 546.48 1,575.12 3,150.24 

Ciprofloxacin 250 mg q 12 h 180.00 420.00 840.00 

500 mg q 12 h 245.70 573.30 1,146.60 

Ofloxacin 200 mg q 12 h 204.78 477.82 955.64 

400 mg q 12 h 256.02 597.38 1,194.76 

Norfloxacin 400 mg q 12 h 120.00 280.00 560.00 

200 mg q 12 h 87.00 203.00 406.00

Cost of antimicrobial prophylaxis regimens for recurrent UTI 

Daily Regimen Cost (pesos)/day 

Nitrofurantoin 50 mg 7.50 

Co-trimoxazole Generic 40/200 mg (1/2 tab) 6.40 

Norfloxacin 200 mg 14.50 

Cephalexin 250 mg 12.01 

500 mg 21.88 

Cost of parenteral regimens for UTI 

Drug/Regimen Cost (peso)/day 

Ampicillin (Generic) 1 g q 6h 406.40 

Ciprofloxacin 200 mg q 12h 1,638.00 

400 mg q 12h 3,276.00 

Ceftriaxone 2 g q 24h 1,910.00 

Co-trimoxazole 160/800 mg q 12h 555.00 

Gentamicin 240 mg q 24h 252.42 

Amikacin 1000 mg q 24h 1,580.00 

ACKNOWLEDGEMENTS 

Public Forum Participants: Regina P. Berba, MD, Ms. Caroline Bigornia, Dolores Banzon, MD, Vilma M. Co, MD, 

Ms. Julita Cabangbang, Loreto J. Codamos, MD, Marietta A. De Luna, MD, Mr. Tomas Eclipse, RN, Agnes Estrella, 

MD, Liberty Fajutrao, MD, Antonio Feliciano, MD, Ruby T. Go, MD, Mr. Mike Gomez, Irmingarda Gueco, MD, 

Policarpio Joves, MD, Ms. Marcela Lagayan, Mary Ann D. Lansang, MD, Julius A. Lecciones, MD, Ma. Lucille K. 

Ledesma, MD, Ricardo M. Manalastas, MD, Agnes D. Mejia, MD, Myrna T. Mendoza, MD, Oscar D. Naidas, MD, 

Benita A. Padilla, MD, Mr. Jesus Quiazon, Ma. Rosarita Quijano, MD, Mrs. Nieves O. Rana, RN, Mediadora C. Saniel, 

MD, Dennis P. Serrano, MD, Jesus Emmanuel A.D. Sevilleja, MD, Erlinda L. Tiuseco, MD, Editha Garcia-Torres, 

MD, Ma. Lourdes Villa, MD. 

Institutions/Organizations represented: Department of Health (Public Health Office), FEU-NRMF College of 

Medicine, Makati Medical Center, Medical Observer, National Kidney and Transplant Institute, <strong>Philippine</strong> Academy of 

Family Physicians, <strong>Philippine</strong> Association of Medical Technologists, <strong>Philippine</strong> Council for Health Research and 

Development, <strong>Philippine</strong> Diabetes Association, Philamcare Health Systems, Inc., 

<strong>Philippine</strong> Nurses Association, Maternal and Child Nurses Association of the <strong>Philippine</strong>s, <strong>Philippine</strong> Obstetrics and Gynecological 

Society, <strong>Philippine</strong> Society for Microbiology and Infectious Diseases, <strong>Philippine</strong> Society of Nephrology, <strong>Philippine</strong> Society of 

Venereologists, <strong>Philippine</strong> Urological Association, Santo Tomas University Hospital, St. Luke’s Medical Center, <strong>The</strong> Medical City, 

UP College of Medicine, UP-<strong>Philippine</strong> General Hospital, UP-PGH <strong>Clinical</strong> Epidemiology Unit, Warner Lambert. 

Acknowledgements to PSMID: For the initiative and effort of the <strong>Philippine</strong> Society for Microbiology and Infectious 

Diseases in convening the PPGG-ID; to the present and past presidents and council members of PSMID for supporting 

the Standards of Care agenda as flagship project of the Society. 

Acknowledgements for providing written comments and critique of CPGs: Angeles Tan-Alora, MD, Conrado S. 

Dayrit, MD, Antonio Feliciano, MD, Deanne Campo-Cruz, MD, Raul Quillamor, MD. 

Acknowledgements for provision/retrieval of research materials: Benjamin M. Limson, MD, Baxter <strong>Philippine</strong>s, 

MSD Resource Center, Pfizer Inc. Funding Sources: Pfizer Foundation, Inc., World Health Organization (Western 

Pacific Regional Office), UP College of Medicine, UNILAB Bayanihan Faculty Grant, (awarded to Dr. Mediadora C. 

Saniel). 

Mediadora C. Saniel, MD 

(Chairman) 

Professor of Medicine 

College of Medicine 

University of the <strong>Philippine</strong>s 

Infectious Diseases Section, 

Department of Medicine 

UP – <strong>Philippine</strong> General Hospital 

Oscar D. Naidas, MD (Co- 

Chairman) 

Associate Professor 

Faculty of Medicine and Surgery 

Santo Tomas University

Cecilia S. Acuin, MD 

Assistant Professor 

College of Medicine De La Salle 

University 

Department of Family and 

Community Medicine 

Loreto J. Codamos, MD 

Head, Research Committee 


St. Luke’s Medical Center 

Ricardo M. Manalastas, Jr. MD 


Department of Obstetrics and 

Gynecology 

UP- <strong>Philippine</strong> General Hospital 

Adrian C. Peña, MD 


Chief 

Section of Infectious Diseases 


UERM Memorial Medical Center 

Evelyn T. Alesna, MD 

Infectious Diseases Consultant 

Cebu City 

Mary Ann D. Lansang, MD 

Professor <strong>Clinical</strong> Epidemiology 

Unit and Infectious Diseases Section 



Agnes D. Mejia, MD 




Section of Nephrology 



Mrs. Nieves O. Rana, RN, MAN 

N6, UP-<strong>Philippine</strong> General Hospital 

Board Member 

Mother and Child Nurses 

Association of the <strong>Philippine</strong>s 

Member, 

<strong>Philippine</strong> Nurses Association 

Editha M. Garcia-Torres, MD 


Section of Microbiology and 

Parasitology 

Department of Medicine and 

Tropical Disease 

UST Hospital 

Regina P. Berba, MD 

Fellow, Infectious Diseases Section 


Ma. Lucille K. Ledesma, MD 

Fellow, Infectious Diseases and Tropical 

Medicine 

St. Luke’s Medical Center 

Benita S. Padilla, MD 

Head, 

Emergency Room and Outpatient 

Department, 

UP-<strong>Philippine</strong> General Hospital 

National Kidney and Transplant Institute 

Board Member 

<strong>Philippine</strong> Society of Nephrology 

Dennis P. Serrano, MD 

<strong>Clinical</strong> Associate Professor 

Department of Surgery 



Expert Panel: Clayton Blas, MD, Deanne Campo-Cruz MBA, Tomas Eclipse, RN, MBA, Agnes Estrella, MD, Liberty 

Fajutrao, MD, Irmingrada Gueco, MD, Ofelia Javellana, MD, Policarpio Joves, MD, Ricardo Manalastas, MD, Raul 

Quillamor, MD, Jesus Emmanuel Seveillaja, MD, Ariel Zerrudo, MD. 

PPGG-ID Coordinator: Julius A. Lecciones, MD

The Philippine Clinical Practice Guideline on the Diagnosis and ...

Create successful ePaper yourself

Delete template?

Save as template?