Urinary Tract Infections (UTIs)
Diagnosis
Common Caustive Organisms
E. coli, Proteus spp., Klebsiella spp.
- While not commin, patients are at increased risk of UTI with Pseudomonas spp. if at least 1 risk factor^ present:
- ^Pseudomonal risk factors include: hospitalization within the last 30 days AND received IV antibiotics, history of prior pseudomonal infection, immunocompromised (uncontrolled HIV, transplant, etc.)
UTI Classification
| Classification | Description |
| Uncomplicated UTI | UTI confined to the bladder in afebrile women or men |
| Complicated UTI | UTI beyond the bladder in women or men (including pyelonephritis, catheter-associated UTI, and bacteremic UTI) |
| Prostatitis, Epididymitis | UTI beyond the bladder unique to male anatomy |
Empiric Outpatient UTI Treatment
***CPRS Ambulatory Care Order Menu Available***
Diagnosis | Preferred Treatment | Duration |
Uncomplicated UTI | Cephalexin 500 mg PO q12h | 7 days |
| Nitrofurantoin 100 mg PO q12h | Male: 7 days Female: 5 days | |
| Ciprofloxacin 500 mg PO q12h (pseudomonas risk^) | 5 days | |
Complicated UTI | Sulfamethoxazole-trimethoprim 1 DS PO q12h | 7 days |
| Cefpodoxime 400 mg PO q12h | 7 days | |
| Ciprofloxacin 500 mg PO q12h (pseudomonas risk^) | 5-7 days | |
Epididymitis | Levofloxacin* 500 mg PO daily | 10 days |
If concerned about sexually transmitted chlamydia and gonorrhea ADD: Doxycycline 100 mg PO BID x7 days AND one-time dose of IM ceftriaxone: Total body weight < 150 kg: ceftriaxone 500 mg IM x1 Total body weight > 150 kg: ceftriaxone 1000 mg IM x1 | ||
Acute bacterial prostatitis | Sulfamethoxazole-trimethoprim 1 DS PO q12h | 14 days |
| Ciprofloxacin 500 mg PO q12h | ||
Chronic prostatitis | Consider consulting urology service | |
Empiric Inpatient UTI Treatment
Diagnosis | Preferred Treatment | Duration |
Uncomplicated UTI | Cephalexin 500 mg PO q12h | 7 days |
| Nitrofurantoin 100 mg PO q12h | Male: 7 days Female: 5 days | |
| Ciprofloxacin* 500 mg PO q12h (pseudomonas risk^) | 5 days | |
Complicated UTI with sepsis | Ceftriaxone 2 gm IV q24h | 7 days |
| Cefepime* 2 gm IV q8h (pseudomonas risk^) | ||
Complicated UTI without sepsis | Ceftriaxone 2 gm IV q24h | 7 days |
| Cefepime* 2 gm IV q12h (pseudomonas risk^) | ||
| Ciprofloxacin* 500 mg PO q12h (pseudomonas risk^) | 5-7 days | |
Acute bacterial Prostatitis | Sulfamethoxazole-trimethoprim 1 DS PO q12h | 14 days |
| Ciprofloxacin* 500 mg PO q12h |
*Contact ASP Pharmacist (preferred) or ID fellow to approve use outside of ICU
^Pseudomonal risk factors include hospitalization within the last 30 days AND received IV antibiotics, history of prior pseudomonal infection, immunocompromised (uncontrolled HIV, transplant, etc.)
Oral Step-down options for complicated UTI (IV to PO)
| Drug | Dose |
| Cefpodoxime* | 400 mg PO q12h |
| Sulfamethoxazole-trimethoprime* | 1-2 DS tablet PO q12h^ |
| Ciprofloxacin* | 500 mg to 750 mg PO q12h |
| Amoxicillin | 1 gm PO q8h |
| Cephalexin | 1000 mg PO q8h |
| Amoxicillin-clavulanate | 875-125 mg PO q8h |
| Levofloxacin | 500 mg to 750 mg PO q24h |
Clinical Pearls
- Tailor therapy to culture results once microbiologic data is available
- Asymptomatic bacteriuria does not require antibiotic therapy for most patients. Antibiotics are only indicated for:
- Pregnancy: cystitis treatment
- Urological procedure: 1 dose prior to procedure and 1 to 2 doses after
- Pseudomonal uncomplicated UTI and complicated UTI without sepsis can be effectively treated with lower doses of cefepime due to high urinary concentrations (~85% excreted unchanged in urine)
- For treatment of complicated UTIs:
- Catheter associated UTIs (CAUTI) require change in catheter
- In patients with delayed clinical improvement:
- Assess for drug-bug mismatch
- Evaluate for an ongoing nidus of infection requiring source control
- Consider longer treatment duration (10-14 days)
- IV to PO stepdown is recommended for patients clinically improving, able to take oral medications, and when there is an effective oral agent that achieves therapeutic concentrations in the urine and is active against the causative pathogen
References:
1. Gupta, Kalpana, 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." Clinical infectious diseases 52.5 (2011): e103-e120.
2. Hooton, Thomas M., et al. "Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America." Clinical infectious diseases 50.5 (2010): 625-663.