Urinary Tract Infections | Infectious Diseases Management Program at UCSF

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.

Diagnosis	Common Pathogens	Drug(s) of First Choice	Alternative Drug(s)	Comments	Expected 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
Candiduria	Candida 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 UTI^1,2. 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 success^6,8. 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:

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
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
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
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
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/)
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
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
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
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
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
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
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
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)
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

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Urinary Tract Infections - Hospital Onset

Patient Population:

Pediatric

Diagnosis is made based on:

Pyuria (>5-10 WBC/HPF on microscopy) AND

At least 50,000 colonies per mL of a single uropathogenic organism in an appropriately collected specimen:

Catheterized (even if bag collection for urinalysis is used for screening, catheterization should be used to collect urine for culture)

Clean catch 

Compatible urinary tract symptoms

Therapy should be modified according to culture and susceptibilities.  For patients with prior UTIs, consider susceptibilities of prior causative organisms when selecting empiric therapy. See Table 1 for inferred susceptibility for enteral antibiotics from IV antibiotic susceptibilities that are routinely reported in BCH Microbiology laboratories. Consider ID/ASP consult for patients with current or recent history of multidrug resistant organisms, such as Extended-Spectrum Beta-lactamase (ESBL) producers. 

Condition	Major Pathogens	First Choice Therapy	Alternative Therapy	Comments
Urinary tract infection, hospital-onset This category is intended for catheter-associated infection, or patients with significant prior antibiotic exposure - for patients at low-risk for antibiotic-resistant organisms, refer to Community-Onset UTI section	Enteric and hospital-acquired gram-negative bacteria including Pseudomonas aeruginosa If the patient has an indwelling urinary catheter or performs clean intermittent catheterization, Enterococcus species and Candida species are more likely to represent colonization. May consider catheter exchange, continue clean intermittent catheterization every 3 hours or as guided by Urology recommendations	Ceftazidime 50 mg/kg/dose (max 2000 mg/dose) IV q8h	Cephalosporin allergy with lower risk for allergic reaction (full dose vs. test dose per Inpatient Beta-Lactam Allergy Guideline): Piperacillin-tazobactam (Zosyn) 100 mg piperacillin/kg/dose (max 4000 mg  piperacillin/dose) IV q6h  Penicillin or cephalosporin allergy with higher risk for allergic reaction: Ciprofloxacin 10 mg/kg/dose (max 400 mg/dose) IV q8h  OR  Ciprofloxacin 15 mg/kg/dose (max 500 mg/dose) enterally bid	Duration: 7 days for most patients, individualized per ID consult guidance for patients with significant complications Consider Urology consult if patient has genitourinary abnormalities Modify therapy based on culture and susceptibility. Change to enteral therapy based on clinical improvement, organism isolated, ability to tolerate enteral therapy. See Table 1, 2 and 3 below for guidance

Condition

Major Pathogens

First Choice Therapy

Alternative Therapy

Comments

Urinary tract infection, hospital-onset

This category is intended for catheter-associated infection, or patients with significant prior antibiotic exposure - for patients at low-risk for antibiotic-resistant organisms, refer to Community-Onset UTI section

Enteric and hospital-acquired gram-negative bacteria including Pseudomonas aeruginosa

If the patient has an indwelling urinary catheter
or performs clean intermittent catheterization, Enterococcus species and Candida species are more likely to
represent colonization. May consider catheter exchange, continue clean intermittent catheterization every 3 hours or as guided by Urology recommendations

Ceftazidime
50 mg/kg/dose (max 2000 mg/dose) IV q8h 

Cephalosporin allergy with lower risk for allergic reaction (full dose vs. test dose per Inpatient Beta-Lactam Allergy Guideline):

Piperacillin-tazobactam (Zosyn)
100 mg piperacillin/kg/dose (max 4000 mg  piperacillin/dose) IV q6h 

Penicillin or cephalosporin allergy with higher risk for allergic reaction:

Ciprofloxacin
10 mg/kg/dose (max 400 mg/dose) IV q8h 

Ciprofloxacin 15 mg/kg/dose (max 500 mg/dose) enterally bid

Duration: 7 days for most patients, individualized per ID consult guidance for patients with significant complications

Consider Urology consult if patient has genitourinary abnormalities

Modify therapy based on culture and susceptibility. Change to enteral therapy based on clinical improvement, organism isolated, ability to tolerate enteral therapy. See Table 1, 2 and 3 below for guidance

Table 1: IV to enteral inferred susceptibility
Ampicillin → amoxicillin (cannot infer susceptibility to cephalosporins)
Ampicillin-sulbactam (Unasyn) → amoxicillin/clavulanate (Augmentin)
Cefazolin MIC <=16 → cephalexin/cefuroxime/cefdinir (cephalexin preferred)
Ceftazidime/Ceftriaxone → N/A (cannot infer susceptibility to 3rd generation oral cephalosporins)
Ciprofloxacin → ciprofloxacin
Trimethoprim-sulfamethoxazole → trimethoprim-sulfamethoxazole (Bactrim or Septra)

Table 2: Preferred enteral antibiotics for definitive therapy
If the patient is able to take enteral therapy and the bacteria is susceptible, recommend narrowing antimicrobial coverage (the following antibiotics are in order of preferential use top to bottom):
1st Tier	Amoxicillin 25 mg/kg/dose (max 500 mg/dose) enterally bid OR Cephalexin 25 mg/kg/dose (max 500 mg/dose) enterally tid
2nd Tier	Trimethoprim-sulfamethoxazole (Bactrim or Septra) 5 mg trimethoprim/kg/dose (max 160mg trimethoprim/dose) enterally bid  OR  Nitrofurantoin monohydrate/macrocrystals (only use in cystitis without pyelonephritis) 100 mg/dose enterally bid
3rd Tier	Amoxicillin/clavulanate (Augmentin) 25 mg amoxicillin /kg/dose (max 500 mg amoxicillin/dose) enterally bid Exception: ESBL-producing organism, contact ASP for guidance.
4th Tier	Ciprofloxacin 15 mg/kg/dose (max 500 mg/dose) enterally bid

Table 3: Preferred IV antibiotics for definitive therapy
IF the patient still needs IV therapy and the bacteria is susceptible, recommend narrowing antimicrobial coverage (the following antibiotics are in order of preferential use top to bottom):
1st Tier	Ampicillin 50 mg/kg/dose (max 2000 mg/dose) IV q6h OR Cefazolin 25 mg/kg/dose (max 2000 mg/dose) IV q8h
2nd Tier	Ampicillin-sulbactam (Unasyn) 50 mg ampicillin/kg/dose (max 2000 mg ampicillin/dose) IV q6h Exception: ESBL-producing organism, contact ASP for guidance. OR Ceftriaxone 50 mg/kg/dose (max 1000 mg/dose) IV q24h OR Trimethoprim-sulfamethoxazole (Bactrim or Septra) 5 mg trimethoprim/kg/dose (max 160 mg trimethoprim/dose) IV q12h
3rd Tier	Ciprofloxacin 10 mg/kg/dose (max 400 mg/dose) IV q8h
4th Tier	Gentamicin 5 mg/kg/dose IV q24h

References:

CLSI supplement M100. Wayne, PA: Clinical and Laboratory Standards Institute; 2020.

Fox, M. T., Amoah, J., Hsu, A. J., Herzke, C. A., Gerber, J. S., & Tamma, P. D. (2020). Comparative effectiveness of antibiotic treatment duration in children with pyelonephritis. JAMA Network Open, 3(5), e203951.

Urinary Tract Infections

Read more about Urinary Tract Infections - Hospital Onset

Urinary Tract Infections - Community Onset

Patient Population:

Pediatric

See further UTI management guidelines from the UCSF Northern California Pediatric Hospital Medicine Consortium, though reference below recommendations for updated antibiotic selection.

Diagnosis is made based on:

Pyuria (>5-10 WBC/HPF on microscopy) AND

At least 50,000 colonies per mL of a single uropathogenic organism in an appropriately collected specimen:

Catheterized (even if bag collection for urinalysis is used for screening, catheterization should be used to collect urine for culture)

Clean catch 

Compatible urinary tract symptoms

Condition	Major Pathogens	First Choice Therapy	Alternative Therapy	Comments
Urinary tract infection < 2 months old	Enteric gram-negative bacteria	In most cases therapy will be initiated per Fever Without a Source - Young Infant guidelines In infants age 28-60 days, if initial evaluation indicates UTI is likely (pyuria on urinalysis), initial oral therapy may be appropriate based on evaluating provider discretion. For infants initially treated with IV therapy, conversion to pathogen-directed enteral therapy is appropriate in most cases after resolution of presenting signs and symptoms of UTI.
Urinary tract infection, community-onset, 2 months-12 years old  Includes febrile UTI in which involvement of upper vs. lower urinary tract cannot be easily distinguished	Enteric gram- negative bacteria	Cephalexin 25 mg/kg/dose (max 500 mg/dose) enterally tid	Penicillin or cephalosporin allergy with higher risk for allergic reaction OR history of prior UTI with cefazolin resistant, Trimethoprim-sulfamethoxazole susceptible organism: Trimethoprim-sulfamethoxazole (Bactrim) 5 mg trimethoprim/kg/ dose (max 160 mg trimethoprim/dose) enterally bid	Duration: 7 days Modify therapy based on culture and susceptibilities Note: Ceftriaxone does NOT predict cefdinir, cefixime or cefpodoxime susceptibility (See Table 1 below for inferred susceptibilities)
Uncomplicated cystitis, > 12 years old	Enteric gram-negative bacteria	Nitrofurantoin monohydrate/ macrocrystals (Macrobid) 100 mg/dose enterally bid	Cephalexin 25 mg/kg/dose (max 500 mg/dose) enterally bid	Duration: 3-5 days Modify therapy based on culture and susceptibilities
Pyelonephritis, community-onset, > 6 months of age	Enteric gram-negative bacteria	Inpatient: Ceftriaxone 50 mg/kg/dose (max 1000 mg/dose) IV q24h  ------------------------ If candidate for enteral therapy: Cephalexin 25 mg/kg/dose (max 500 mg/dose) enterally tid	Penicillin or cephalosporin allergy with higher risk for allergic reaction: Inpatient: Ciprofloxacin 10 mg/kg/dose (max 400 mg/dose) IV q8h ------------------------- If candidate for enteral therapy: Ciprofloxacin 15 mg/kg/dose (max 500 mg/dose) enterally bid	ID consult recommended for complicated infection, concurrent bacteremia, or inadequate response to initial therapy Consider Urology consult if patient has urinary tract abnormalities Duration:  7 days for most patients, individualized per ID consult guidance for patients with significant complications  Transition IV to enteral once patient is able to tolerate enteral route. Modify therapy based on culture and susceptibilities. See Table 1 and Table 2 below.

Table 1: IV to enteral inferred susceptibility
Ampicillin → amoxicillin (cannot infer susceptibility to cephalosporins)
Ampicillin-sulbactam (Unasyn) → amoxicillin/clavulanate (Augmentin)
Cefazolin MIC <=16 → cephalexin/cefuroxime/cefdinir (cephalexin preferred)
Ceftazidime/Ceftriaxone → N/A (cannot infer susceptibility to 3rd generation oral cephalosporins)
Ciprofloxacin → ciprofloxacin
Trimethoprim-sulfamethoxazole → trimethoprim-sulfamethoxazole (Bactrim or Septra)

Table 2: Prefered enteral antibiotics for definitive therapy
If the patient is able to take enteral therapy and the bacteria is susceptible, recommend narrowing antimicrobial coverage (the following antibiotics are in order of preferential use top to bottom):
1st Tier			Amoxicillin 25 mg/kg/dose (max 500 mg/dose) enterally bid OR Cephalexin 25 mg/kg/dose (max 500 mg/dose) enterally tid
2nd Tier			Trimethoprim-sulfamethoxazole (Bactrim or Septra) 5 mg trimethoprim/kg/dose (max 160 mg trimethoprim/dose) enterally bid  OR  Nitrofurantoin monohydrate/macrocrystals (Macrobid) (only use in cystitis without pyelonephritis) 100 mg/dose enterally bid
3rd Tier			Amoxicillin-clavulanate (Augmentin) 25 mg amoxicillin/kg/dose (max 500 mg amoxicillin/dose) enterally bid Exception: ESBL-producing organism, move to 4th tier for clinically stable outpatient, otherwise contact ASP for guidance about other options.
4th Tier			Ciprofloxacin 15 mg/kg/dose (max 500 mg/dose) enterally bid

References:

American Academy of Pediatrics Subcommittee on Urinary Tract Infection. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011;128:595-610.

CLSI supplement M100. Wayne, PA: Clinical and Laboratory Standards Institute; 2020.

Gupta K, 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:e103-e120.

American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021. 

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