When presented with a urinary tract infection, you have to ask:
- Cystitis or pyelonephritis?
- Lower UTI – cystitis: dysuria, frequent urination, urgency, hematuria
- Upper UTI – pyelonephritis: frequency, dysuria, hematuria, suprapubic pain, flank pain, tenderness, elevated WBC, nausea/vomiting, casts in urine
- Complicated or Uncomplicated
- Complicated: males, hospital-acquired, pregnancy, anatomic abnormality of the urinary tract, history of childhood UTI, recent antimicrobial use, indwelling catheter, immunosuppression, recent urinary tract instrumentation
- Recurrent cystitis: infection within 14 days of the previous antibiotic discontinuation
Treatment:
- Uncomplicated cystitis:
- Bactrim BID for 3 days
- nitrofurantoin 100 mg BID * 5 days
- fosfomycin 3 g for 1 dose
- fluoroquinolone for 3 days if persistent. Avoid if other options.
- beta-lactam for 7 days
- Uncomplicated pyelonephritis:
- outpatient:
- Bactrim for 14 days
- fluoroquinolone for 5-7 days (2nd line)
- beta-lactam for 10-14 days (3rd line)
- When uropathogen resistance is greater than 10%, use an initial dose of ceftriaxone or an aminoglycoside
- outpatient:
- Complicated UTI:
- all are in inpatient:
- fluoroquinolone for 5 days
- aminoglycoside for 14 days
- extended spectrum beta-lactam for 14 days (usually ceftriaxone)
- pregnancy
- 7-day treatment
- amoxicillin
- nitrofurantoin (avoid if other options)
- cephalexin
- avoid FQs, tetracyclines, aminoglycosides, Bactrim in last trimester
- recurrent cystitis
- longer treatment (2-6 weeks)
- If patient has 2 or fewer recurrent infections, use patient initiated therapy
- If patient has 3 or more and they are related to sex, use intercourse prophylaxis with Bactrim, cephalexin or nitrofurantoin
- If 3 or more not related to sex, daily or 3 times a week prophylaxis with
- Bactrim, cephalexin or nitrofurantoin
- Catheter-related UTI
- About 5% of patients with catheter will develop a UTI per day (by day 30, up to 95% will have UTI).
- Only treat symptomatic patients.
- Usually caused by E.coli, candida, enterococcus, Pseudomonas, K. pneumonia, enterbacter
- Treat for 7 days if symptoms resolve promptly, 14 days if not
- Prostatitis and epididymitis
- Usually gram 1 organisms
- Treat for 4 weeks
- For chronic bacterial prostatitis, give therapy for 1-4 months with Bactrim or a fluoroquinolone
- Epididymitis
- If older than 35, probably caused by enteric organisms. Treat for 10 days to 4 weeks.
- If younger than 35, probably gonococcal or chlamydial. Treat with ceftriaxone 250 mg times one and doxycycline BID for 10 days.
- all are in inpatient: