Asymptomatic Bacteriuria

Positive urine culture in the absence of symptoms regardless of urinalysis results. Asymptomatic bacteriuria does NOT need to be treated unless the patient is pregnant or undergoing urologic instrumentation when bleeding is anticipated (e.g. TURP).

Urinary tract infections (UTI)

Cystitis or pyelonephritis which occurs in healthy, nonpregnant women with no functional or anatomic abnormalities of the urinary tract.

Uncomplicated UTI

Cystitis or pyelonephritis which occurs in healthy, nonpregnant women with no functional or anatomic abnormalities of the urinary tract.

Complicated UTI

  • Male gender
  • Pregnancy
  • Neurogenic bladder
  • Functional or structural abnormality of GU tract
  • Nephrolithiasis
  • Obstruction
  • Indwelling catheter
  • Unresolved or recurrent UTI
  • Nosocomial UTI

Empiric Regimen

Therapy should be streamlined once culture and sensitivity results are available

Uncomplicated Cystitis

Preferred RegimensUsual Duration
Nitrofurantoin (1) (Macrobid)
100 mg po BID		Female x 5 days
Male x 7 days
TMP/SMX(2,3)
1 DS po BID		Female x 3 days
Male x 7 days
Cephalexin 500mg QID (2)
Female x 5-7 days
Male x 7 days
Amoxicillin clavulanate 875/125mg BID (2)Female x 5-7 days
Male x 7 days
Fosfomycin 3gone time dose
Ciprofloxacin 500mg BID (2,4)
Female x 3 days
Male x 7 days

Complicated Cystitis

Factors to consider include age > 55 years, male, symptoms > 7 days, diabetes mellitus, structural abnormalities of urinary tract such as stricture and renal calculi, spinal cord injury or recurrent UTI

  1. TMP / SMX 1 DS BID (2,3)
  2. Cephalexin 500mg QID (2) OR Amoxicillin clavulanate 875/125 BID (2)
  3. Ciprofloxacin 500mg BID (2,4)
  4. Fosfomycin 3g PO q72h x 3 doses (limited data for complicated UTI)

Usual duration for any above regimen for complicated cystitis is 7 days. May need to extend treatment up to 14 days for structural abnormalities or catheterized patients

Pyelonephritis

NO risk factors for resistance (young, community dwelling patient, minimal antibiotic exposure)

Should collect 2 sets of blood cultures before initiation of antibiotics

IV (choose one of the following)Oral (choose one of the following)
Ceftriaxone 1g IV q24h
OR
Tobramycin 5-7 mg/kg IV daily (based on ideal body weight) (2)		1. TMP/ SMX 1 DS BID (2,3)
2. Ciprofloxacin 500mg BID (2,4)
3. Cephalexin 500mg QID (2,5) OR amoxicillin-clavulanate 875/125mg BID (2,5)

Risk factors for resistance (previous hospitalization, LTC / nursing home, antibiotic exposure within 90 days):

IV Ceftriaxone OR IV tobramycin as above (empiric use of oral antibiotics is discouraged due to high resistance rates)

  • Streamline as per C&S results
  • Stepdown to PO therapy when appropriate
  • Duration is typically 10-14 days with a beta lactam agent, or if patients have underlying urologic abnormalities or stents (7 days if fluoroquinolone is used for susceptible pathogens)
UTI-algorithm-May-2020Download

Footnotes

  1. Nitrofurantoin is not recommended for treatment of pyelonephritis or prostatitis because of insufficient tissue levels.  It may be an option for VRE cystitis.  If CrCl < 60ml/min or in the presence of anuria, oliguria, avoid use of nitrofurantoin.  Should avoid in pregnant patients greater than or equal to 36 weeks
  2. Renal dosage adjustment is required.
  3. Consider alternatives in first trimester and > 34 weeks.
  4. Use ciprofloxacin only if no alternative agent available. NOTE: > 20% of urinary pathogens are resistant to fluroquinolones
  5. Oral beta lactams have higher relapse rates and inferior efficacy compared to fluoroquinolones or TMP/SMX