Sandbox Urinary tract infection medical therapy

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Urinary Tract Infection Microchapters

Patient Information

Overview

Classification

Pyelonephritis
Cystitis
Prostatitis
Urethritis
Asymptomatic bacteriuria

Causes

Differential Diagnosis

Treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Most uncomplicated UTIs can be treated with oral antibiotics such as trimethoprim, cephalosporins, nitrofurantoin, or a fluoroquinolone (e.g. ciprofloxacin, levofloxacin). These are usually taken for 3 days in young adults, and 5 days in elderly. Whilst co-trimoxazole was previously internationally used (and continues to be used in the U.S.), the additional of the sulphonamide gave little additional benefit compared to the trimethoprim component alone, but was responsible for its both high incidence of mild allergic reactions and rare but serious complications.

If the patient has symptoms consistent with pyelonephritis, intravenous antibiotics may be indicated. Regimens vary, usually Aminoglycosides (such as Gentamicin) are used in combination with a beta-lactam, such as Ampicillin or Ceftriaxone. These are continued for 48 hours after fever subsides. The patient may then be discharged home on oral antibiotics for a further 5 days.

If the patient makes a poor response to IV antibiotics (marked by persistent fever, worsening renal function), then imaging is indicated to rule out formation of an abscess either within or around the kidney, or the presence of an obstructing lesion such as a stone or tumor. The gold-standard imaging modality is CT scan.

Empiric Therapy for Acute Pyelonephritis (Outpatient & Inpatient) Adapted from Clin Infect Dis. 2011;52(5):e103-20.[1]

Acute Pyelonephritis, Outpatient
Preferred Regimen
Ciprofloxacin 500 mg PO q12h x 7 days ± Ciprofloxacin 400 mg IV x 1 dose
OR
Ciprofloxacin XR 1000 mg PO q24h for 7 days
OR
Levofloxacin 750 mg PO q24h for 5 days
PLUS (if fluoroquinolone resistance >10%)
Ceftriaxone 1 g IV x 1 dose
OR
Gentamicin 7 mg/kg IV x 1 dose
OR
Tobramycin 7 mg/kg IV x 1 dose
OR
Amikacin 20 mg/kg IV x 1 dose
Alternative Regimen 1
TMP/SMZ 160/800 mg PO q12h x 14 days
PLUS (if TMP/SMZ resistance unknown)
Ceftriaxone 1 g IV x 1 dose
OR
Gentamicin 7 mg/kg IV x 1 dose
OR
Tobramycin 7 mg/kg IV x 1 dose
OR
Amikacin 20 mg/kg IV x 1 dose
Alternative Regimen 2
Amoxicillin–Clavulanate 500/125 mg PO q12h x 14 days
OR
Amoxicillin–Clavulanate 250/125 mg PO q8h x 5–7 days
OR
Cefaclor 500 mg PO q8h x 7 days
PLUS
Ceftriaxone 1 g IV x 1 dose
OR
Gentamicin 7 mg/kg IV x 1 dose
OR
Tobramycin 7 mg/kg IV x 1 dose
OR
Amikacin 20 mg/kg IV x 1 dose
Acute Pyelonephritis, Inpatient
Preferred Regimen
Ciprofloxacin 400 mg IV q12h
OR
Levofloxacin 750 mg IV q24h
Alternative Regimen 1
Gentamicin 7 mg/kg IV q24h ± Ampicillin 500 mg IV q6h
OR
Tobramycin 7 mg/kg IV q24h ± Ampicillin 500 mg IV q6h
OR
Amikacin 20 mg/kg IV q24h ± Ampicillin 500 mg IV q6h
Alternative Regimen 2
Cefotaxime 1–2 gm IV q8h
OR
Ceftriaxone 1 gm IV q24h
OR
Ceftazidime 2 gm IV q8h
OR
Ampicillin-Sulbactam 1.5 g IV q6h
OR
Piperacillin-Tazobactam 3.375 gm IV q4–6h
OR
Ticarcillin-Clavulanate 3.1 gm IV q4–6h
WITH OR WITHOUT
Gentamicin 7 mg/kg IV q24h
OR
Tobramycin 7 mg/kg IV q24h
OR
Amikacin 20 mg/kg IV q24h
Alternative Regimen 3
Meropenem 500 mg IV q8h
OR
Ertapenem 1 g IV q24h
OR
Doripenem 500 mg IV q8h
OR
Aztreonam 1 g IV q8–12h
Antibiotics should be administered for at least 10–14 days based on local resistance patterns.
De-escalation to oral antibiotcs may be considered 24–48 hours after defervescence.

Empiric Therapy for Acute Pyelonephritis (Pregnancy) Adapted from European Association of Urology's Guidelines on Urological Infections [2]

Pyelonephritis, Pregnancy
Preferred Regimen
Ceftriaxone 1-2 g IV or IM q24 h
OR
Aztreonam 1 g IV q8-12 h
OR
Piperacillin-tazobactam 3.375-4.5 g IV q6h
OR
Cefepime 1 g IV q12 h
OR
Imipenem-cilastatin 500 mg IV q6 h
OR
Ampicillin 2 g IV q6 h
PLUS
Gentamicin 3-5 mg/kg/day IV in 3 divided doses

==Empiric Therapy for Acute Cystitis== Adapted from Clin Infect Dis. 2011;52(5):e103-20.[1]


Acute Bacterial Uncomplicated Cystitis
Preferred Regimen
Nitrofurantoin 100 mg PO q12h × 5 days
OR
TMP 100 mg PO q12h ×3 days
OR
Fosfomycin 3 gm PO single dose
OR If resistence<20% or if used for UTI >3 months
TMP-SMX ‡ 1 DS tab PO q12h × 3 days
OR Not FDA approved but used in some European countries
Pivmecillinam 400 mg PO q12h 3-7 days
Alternative Regimen
Fluoroquinolones for 3 days
Ofloxacin 200–400 mg PO bid
OR
Ciprofloxacin 250 mg bid PO or Cipro XR 500 mg q24h
OR
Levofloxacin 250–750 mg PO q24
OR β-lactam agents for 3-7 days
Amoxicillin-clavulanate 500/125 mg PO q8h or 875/125 mg PO q8h
OR
Cefdinir 300 mg PO q12h or 600 mg PO q24
OR
Cefaclor 250-500 mg PO q8h
OR
Cefpodoxime proxetil 100-200 mg PO q12h
OR
Cephalexin250-500 mg PO q6h not studied well but effective.
Complicated/Catheter Associated Cystitis
Preferred Regimen
Mild Infection
Levofloxacin 750 mg PO q24 × 5 days
Delayed Response
Levofloxacin 750 mg PO q24 × 10-14 days
After Catheter Removal
Levofloxacin 750 mg PO q24 × 3 days
Acute Cystitis in Pregnancy
Preferred Regimen
Nitrofurantoin 100 mg PO q12h × 3-5 days
OR
Fosfomycin 3 g PO single dose
OR
Amoxicillin-clavulanate 500/125 mg PO q12h × 3-5 days
OR
Amoxicillin 500 mg PO q12h × 3-5 days
OR
Cephalexin 500 mg PO q12h × 3-5 days
OR
TMP-SMX DS 1 tab PO q12h × 3-5 days
avoid in first trimester(TMP) and third trimester (SMX).

References

  1. 1.0 1.1 Gupta, K.; Hooton, TM.; Naber, KG.; Wullt, B.; Colgan, R.; Miller, LG.; Moran, GJ.; Nicolle, LE.; Raz, R. (2011). "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. 52 (5): e103–20. doi:10.1093/cid/ciq257. PMID 21292654. Unknown parameter |month= ignored (help)
  2. "http://www.uroweb.org/gls/pdf/18_Urological%20infections_LR.pdf" (PDF). External link in |title= (help)