Please note that this guide goes with current guidelines, but current guidelines don’t really meet practice. IDSA is due with new guidelines in 2024 and a preview was presented at IDweek in 2023/ECCMID 2024. It will change the definition of complicated UTIs to include pyelonephritis, catheter-associated UTI (CAUTI), UTI with fever or other evidence of systemic or upper tract infection and uncomplicated UTI to be everything else. Classically guidelines suggest all UTI in men are complicated, but that’s not the case (must look for prosthetic involvement). See slides at the end of this.
The selection of empiric antibiotics for complicated UTI will include a four-step process. Clinicians should review (1) severity of illness, (2) risk factors for resistant organisms, (3) patient factors, and (4, only if septic) antibiogram. Preferred agents: fluoroquinolones, 3rd/4th generation cephalosporins, piperacillin-tazobactam, (if septic) carbapenems. A 7 day duration is recommended rather than a longer course if clinical improvement is demonstrated.
These are not CURRENT guidelines, but may be current practice.
- 2009 IDSA Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adult
- 2010 IDSA/ESMID International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women
- 2019 IDSA Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria
- 2022 AUA/CUA/SUFU Recurrent Uncomplicated Urinary Tract Infections in Women
When presented with a urinary tract infection, you have to ask:
- Cystitis or pyelonephritis?
- Lower UTI – cystitis: dysuria, frequent urination, urgency, suprapubic pain, hematuria
- Upper UTI – pyelonephritis: same as above plus systemic symptoms like fever chills, flank pain, CVA tenderness, nausea and vomiting
- Complicated or Uncomplicated
- Complicated: associated with a structural or functional abnormality of the urinary tract or significant medical or surgical comorbidities: indwelling foley catheter, ureteral stents, prostatic hyperplasia, nephrolithiasis, tumor, fibrosis, urethral stricture, voiding disorders like neurogenic bladder or intrinsic renal disease,
- Also consider if patient has recent hospitalization, pregnancy, history of childhood UTI, recent antimicrobial use, immunosuppression
- Recurrent cystitis: an infection within 14 days of the previous antibiotic discontinuation
- Most frequent causes of UTI include: E. coli, K. pneumoniae, S. saprophyticus, Enterococcus spp, Group B Strep, Proteus mirabilis, Pseudomonas, S. aureus, Candida
Asymptomatic Bacteriuria:
DO NOT TREAT ASYMPTOMATIC BACTERIURIA unless your patient is a pregnant women or patient undergoing urologic procedures. All pregnant women should be treated for a positive urine bacteria screen regardless of symptoms. Treatment decreases the risk of pyelonephritis, preterm labor, and low birth weight.
Screening only recommended for asymptomatic people if pregnant or undergoing Transurethral resection of the prostate (TURP) or bladder, ureteroscopy, including lithotripsy, percutaneous nephrolithotomy/nephrolithotripsy.
Treatment:
Treat based on microbiology when possible. For complicated UTIs associated with urinary instrumentation, remove if possible.
If inpatient, IV antibiotics are preferred initially, but may transition within 72 hours if improvement. Outpatients usually can be managed orally.
- Uncomplicated cystitis:
- Bactrim BID for 3 days (only if local resistance <20%)
- Nitrofurantoin 100 mg BID * 5 days ONLY FOR CYSTITIS doesn’t work systemically
- Fosfomycin 3 g for 1 dose
- Second line:
- Fluoroquinolone like Cipro or Levaquin for 3 days if persistent. Avoid if other options.
- Beta-lactam for 3-7 days
- Uncomplicated pyelonephritis:
- outpatient:
- Ciprofloxacin 500 mg orally twice daily for 7 days or levofloxacin 750 mg orally daily for 5 days if resistance rates are <10%
- If >10% FQ resistance, IV ß-lactam or aminoglycoside is recommended to start
- Bactrim orally twice daily for 14 days
- Oral ß-lactam antibiotics after a single dose of IV ß-lactam or aminoglycoside for 10-14 days
- IV Beta-lactam preferred initially if patient presents with systemic symptoms and hospitalization is required
- outpatient:
- When uropathogen resistance is greater than 10%, use an initial dose of ceftriaxone or an aminoglycoside
Complicated UTI
- Complicated UTI
- Source control is the best treatment: Relieve obstruction, exchange catheters, drain infected fluid collections
- Intravenous therapy preferred initially for patients requiring hospitalization:
- Treat based on local resistance for 7-14 days, longer if no source control
- fluoroquinolone for 5 days (Levofloxacin 750 mg every 12 hr)
- aminoglycoside for 14 days
- extended spectrum beta-lactam for 14 days (usually ceftriaxone)
- Pregnancy
- 3-7-day treatment
- amoxicillin 500 mg every 8 hours
- nitrofurantoin 100 mg every 12 hours – good for severe PCN allergy
- cephalexin 500 mg every 6 hours, cefpodoxime 100 mg every 12 hours, or cefuroxime 250 mg every 12 hours
- fosfomycin 3 g as a single dose
- avoid FQs, tetracyclines, aminoglycosides, and Bactrim in last trimester due to folate antagonism
- 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.
- Gram – bacteremia due to UTI
- Most are uncomplicated BSI if source control is achieved.
This is a preview of the upcoming guidelines: