Empiric treatment of urinary tract infections

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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


If no prompt resolution of


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



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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