Empiric treatment of urinary tract infections

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EMPIRIC TREATMENT OF URINARY TRACT INFECTIONS

Clinical Setting Asymptomatic bacteriuria or candiduria No symptoms of UTI

Likely Pathogens E. coli, K. pneumoniae, other Enterobactericeae, Enterococcus spp., Candida

Uncomplicated cystitis Symptoms of bladder infection in a nonpregnant woman

E. coli, K. pneumoniae, other Enterobactericeae

Empiric Therapya,b

Usual Durationa

Treatment of asymptomatic bacteriuria is generally not

recommended. Pyuria alone is not an indication for

treatment. If a urethral catheter is in place, removal is

recommended. Treatment is recommended in the following

settings: pregnancy, prior to traumatic genitourinary

procedures (e.g. cystoscopy, TURP), and in some renal

transplant patients. First line: nitrofurantoinc

Nitro: 5 days

TMP-SMX: 3 days

Alternatives: TMP-SMX,

Fosfomycin: 1 dose

fosfomycin, ciprofloxacin Cipro: 3 days

PO beta lactam: 3-7 days

Complicated UTI

E. coli, K.

First line: ceftriaxone

Symptoms of kidney pneumoniae, other

If prompt resolution of symptomse: 7 days

or bladder infection Enterobactericeae Alternatives: gentamicin,

If no prompt resolution of

in a patient meeting specific criteriad

ciprofloxacin, TMP-SMX

symptoms: 7-14 days

Uncomplicated pyelonephritis

E. coli, K.

First line: ceftriaxone

pneumoniae, other

If prompt resolution of symptomse: 7 days

Symptoms of kidney Enterobactericeae Alternatives: gentamicin,

If no prompt resolution of

infection in a

ciprofloxacin, TMP-SMX

symptoms: 7-14 days

nonpregnant woman

Sepsis with urinary E. coli, K.

First line: ceftriaxone ?

If prompt resolution of

tract infection

pneumoniae, other

vancomycine ? gentamicin symptomse: 7 days

Enterobactericeae

If no prompt resolution of

Alternatives:

symptoms: 7-14 days

piperacillin/tazobactam, cefepime ? vancomycinf, aztreonam ? vancomycinf

Candida UTI

Candida spp.

Symptoms of kidney

First line: fluconazole

If prompt resolution of symptomse: 7 days

or bladder infection

Alternatives: conventional

If no prompt resolution of

with a urine culture

amphotericin B (for

symptoms: 7-14 days

positive for Candida

fluconazole-resistant

spp.

Candida spp.)

a Antibiotic therapy should be tailored based on susceptibility results

b If the patient had a documented multidrug resistant organism in the last 90 days, consider previous isolate susceptibility results

when selecting empiric therapy c Avoid nitrofurantoin in patients with creatinine clearance less than 50 mL/min d Criteria for complicated pyelonephritis include: pregnancy; male; diabetes; urinary tract obstruction; presence of an indwelling

urethral catheter (removal indicated), stent, nephrostomy tube or urinary diversion; renal transplantation; immunosuppression;

functional or anatomic abnormality of the urinary tract e Prompt resolution of symptoms: defervescence, resolving urinary symptoms, and normalizing WBC within 72 hours f Vancomycin may be added if suspected gram positive organisms

References 1. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM; Infectious Diseases Society of America; American Society of Nephrology;

American Geriatric Society. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults.Clin Infect Dis. 2005 Mar 1;40(5):643-54. 2. Gupta K, Hooton TM, Roberts PL, Stamm WE. Short-course nitrofurantoin for the treatment of acute uncomplicated cystitis in women. Arch Intern Med. 2007 Nov 12;167(20):2207-12. 3. Talan DA, Stamm WE, Hooton TM, Moran GJ, Burke T, Iravani A, Reuning-Scherer J, Church DA. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis pyelonephritis in women: a randomized trial. JAMA. 2000 Mar 22-29;283(12):1583-90. 4. Peterson J, Kaul S, Khashab M, Fisher AC, Kahn JB. A double-blind, randomized comparison of levofloxacin 750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for the treatment of complicated urinary tract infections and acute pyelonephritis. Urology. 2008 Jan;71(1):17-22. 5. Drekonja DM, Rector TS, Cutting A, Johnson JR. Urinary tract infection in male veterans: treatment patterns and outcomes. JAMA Intern Med. 2013 Jan 14;173(1):62-8. 6. Kyriakidou KG, Rafailidis P, Matthaiou DK, Athanasiou S, Falagas ME. Short- versus long-course antibiotic therapy for acute pyelonephritis in adolescents and adults: a meta-analysis of randomized controlled trials. Clin Ther. 2008 Oct;30(10):1859-68. 7. Pappas PG1, Kauffman CA, Andes D, Benjamin DK Jr, Calandra TF, Edwards JE Jr, Filler SG, Fisher JF, Kullberg BJ, Ostrosky-Zeichner L, Reboli AC, Rex JH, Walsh TJ, Sobel JD; Infectious Diseases Society of America. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Mar 1;48(5):503-35. doi: 10.1086/596757.

Revised: 3/19/2015

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