Urinary Tract Infection (UTI)

Patient Population:
Adult

 

Recommendations updated as of 8/2026

Classifications:

Urinary tract infection treatment is dependent on site of infection, broadly divided into infection involving the upper urinary tract (such as pyelonephritis) and infection confined to the lower urinary tract (cystitis). Prostatitis is treated differently due to poor antibiotic penetration into the prostate and difficulty of eradicating infections at this site. Longer durations for “complicating” factors such as presence of a catheter, stones, or urinary tract abnormalities have not been shown to be beneficial or more effective. See further comments below the table.

DiagnosisCommon PathogensDrug(s) of First ChoiceAlternative Drug(s)CommentsExpected Duration
Asymptomatic bacteriuria

Enterobacterales

Enterococcus spp.

No antibiotic treatment, regardless of pyuria or bacteriuria, in most circumstances Exceptions:
Pregnancy
Undergoing endoscopic urologic procedures associated with mucosal trauma
Recent renal transplant (< 3 months)		0 days
CandiduriaCandida spp.Treatment usually not indicated Candida is rarely a cause of true UTI. Pyuria is not an indication for treatment. Consider ID c/s if true infection suspected.0 days
Lower tract UTI (i.e. cystitis) 

Enterobacterales

Staphylococcus saprophyticus (less common)  

Nitrofurantoin

OR

Trimethoprim/Sulfamethoxazole (TMP/SMX) 

Cephalexin

OR

Ciprofloxacin

OR

Fosfomycin PO

 Nitrofurantoin: 5 days
TMP/SMX: 3 days
Ciprofloxacin: 3 days
Fosfomycin PO: 1 dose
Cephalexin: 5-7 days
IV therapy: 3 days
Upper tract UTI (i.e. pyelonephritis) Enterobacterales

No prior known resistance:

Ceftriaxone

Hemodynamically unstable OR Blood or urine culture with ceftriaxone-resistant organism in the past 12 months:

Ertapenem

Outpatient: Ceftriaxone IM x1 then ciprofloxacin while awaiting susceptibilities

For severe Beta-Lactam Allergy (Type II-IV reaction):

Aztreonam

Switch to oral therapy once susceptibilities are known, patient can tolerate and absorb oral medications, and is stable

5 days

(7 days if bacteremic)

Prostatitis

Acute:
Enterobacterales
N. gonorrhoeae
C. trachomatis

Chronic:
Enterobacterales

Ciprofloxacin

OR

Trimethoprim/Sulfamethoxazole (TMP/SMX) 

 

Consider urologic evaluation

For acute cases, test for N. gonorrhoeae and C. trachomatis in sexually active patients and treat as indicated

Cultures should be obtained and definitive therapy should be based on susceptibilities

Acute:
2-4 weeks

Chronic:
6-8 weeks  

Site of infection:

  • Lower urinary tract infection: infection confined to the bladder (lower urinary tract) in afebrile patients, regardless of gender  
    • Lower urinary tract symptoms include: dysuria, urinary frequency or urgency, suprapubic pain
  • Upper urinary tract infection: infection beyond the bladder (upper urinary tract)
    • Upper urinary tract symptoms include: flank pain, costovertebral angle tenderness, fever  
  • Asymptomatic bacteriuria: positive urine culture in the absence of urinary or systemic symptoms

Oral β-lactams, including cephalosporins, are reasonable step-down options for patients with upper tract urinary tract infection who have received initial IV therapy (48-72 hours) and are clinically improving. A recent systematic review of 17 observational studies evaluating oral β-lactams for complicated UTI found clinical success rates exceeding 90%, comparable to fluoroquinolones or trimethoprim-sulfamethoxazole7. For bacteremic patients, see bacteremia step down guidelines.

Based on susceptibility results, it is reasonable to transition to amoxicillin-clavulanate, cephalexin, cefpodoxime, or cefuroxime in cases when fluoroquinolones or TMP/SMX cannot be used (resistance profiles, allergies, renal dysfunction, etc.). Do not use oral β-lactam antibiotics for ESBL or AmpC producing organisms.

Asymptomatic bacteriuria (ASB) is common among hospitalized patients, particularly older adults, patients with urinary catheters, and residents of long-term care facilities, in whom bacteriuria and pyuria are highly prevalent. Detection of bacteriuria or pyuria alone does not establish a diagnosis of UTI1,2. Treatment of ASB is not recommended in most patient populations, as antimicrobial therapy has not been shown to improve clinical outcomes and is associated with increased rates of adverse drug effects, Clostridioides difficile infection, antimicrobial resistance, and increased health care costs.

Altered mental status (AMS), delirium, or confusion alone, in the absence of localizing genitourinary symptoms or systemic signs of infection, should not be considered evidence of UTI. There is insufficient evidence to establish a reliable causal association between bacteriuria and delirium9, or that treating ASB improves delirium outcomes in older adults with pyuria or bacteriuria without signs or symptoms of infection12.

In clinically stable patients without urinary symptoms (e.g., dysuria, frequency, urgency, suprapubic pain, flank pain) or systemic signs of infection, antibiotics should generally be withheld even when urine cultures are positive.  

“Complicated” UTI

Historically defined as a heterogeneous set of criteria including patients with nephrolithiasis, anatomic abnormalities, presence of a catheter, urinary infection in men, and upper tract infection. More recent IDSA guidelines have limited the definition to infections outside of the bladder, but also included infection in patients with a catheter, without citing evidence that longer treatment durations are required in these patients5. Short durations of therapy in patients with catheter associated urinary tract infections has demonstrated good clinical success6,8. European guidelines also endorse a similar approach focused on site of infection13. Catheter exchange may improve risk of relapse and rate of treatment success, but evidence is limited and mixed14.

References:

  1. Advani SD, North R, Turner NA, et al. Performance of Urinalysis Parameters in Predicting Urinary Tract Infection: Does One Size Fit All? Clin Infect Dis. 2024;79(3):600-603. doi:10.1093/cid/ciae230
  2. Cheng B, Zaman M, Cox W. Correlation of Pyuria and Bacteriuria in Acute Care. The American Journal of Medicine. 2022;135(9):e353-e358. doi:10.1016/j.amjmed.2022.04.022
  3. Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-e120. doi:10.1093/cid/ciq257
  4. Hobbs ALV, Hemmige VS, Reel KL, Jaso TC, Rose DT, Shea KM. Rise of the beta-lactams: a retrospective, comparative cohort of oral beta-lactam antibiotics as step-down therapy for hospitalized adults with acute pyelonephritis. Antimicrob Steward Healthc Epidemiol. 2024;4(1):e102. doi:10.1017/ash.2024.70
  5. IDSA. Complicated Urinary Tract Infections. Accessed August 18, 2026. [https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections/](https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections/)
  6. Jarrell AS, Wood GC, Ponnapula S, et al. Short-duration treatment for catheter-associated urinary tract infections in critically ill trauma patients. J Trauma Acute Care Surg. 2015;79(4):649-653. doi:10.1097/TA.0000000000000822
  7. Kunz Coyne AJ, Bouchard J, Durham SH, et al. Oral β-Lactams for Complicated Urinary Tract Infections: A Systematic Review and Point-Counterpoint Comparison With Trimethoprim/Sulfamethoxazole and Fluoroquinolones. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2026;46(3):e70118. doi:10.1002/phar.70118
  8. Langford BJ, Daneman N, Diong C, et al. Antibiotic Selection and Duration for Catheter-Associated Urinary Tract Infection in Non-Hospitalized Older Adults: A Population-Based Cohort Study. Antimicrob Steward Healthc Epidemiol. 2023;3(1):e132. doi:10.1017/ash.2023.176
  9. Mayne S, Bowden A, Sundvall PD, Gunnarsson R. The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing - a systematic literature review. BMC Geriatr. 2019;19:32. doi:10.1186/s12877-019-1049-7
  10. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):e83-e110. doi:10.1093/cid/ciy1121
  11. Saad S, Mina N, Lee C, Afra K. Oral beta-lactam step down in bacteremic E. coli urinary tract infections. BMC Infect Dis. 2020;20:785. doi:10.1186/s12879-020-05498-2
  12. Stall NM, Kandel C, Reppas-Rindlisbacher C, et al. Antibiotics for delirium in older adults with pyuria or bacteriuria: A systematic review. J Am Geriatr Soc. 2024;72(8):2566-2578. doi:10.1111/jgs.18964
  13. The Guideline - EAU Guidelines on Urological Infections - Uroweb. Accessed August 18, 2026. [https://uroweb.org/guidelines/urological-infections/chapter/the-guideline](https://uroweb.org/guidelines/urological-infections/chapter/the-guideline)
  14. Westgeest AC, van Uhm JIM, Pattacini L, et al. Catheter replacement in catheter-associated urinary tract infection: current state of evidence. Eur J Clin Microbiol Infect Dis. 2024;43(8):1631-1637. doi:10.1007/s10096-024-04878-9
Urinary Tract Infections