Purpose: Urinary tract infection (UTI) treatment guidelines. Gives background, local microbiology data, and suggested empiric regimens.
Source: F. Palmieri, Bronx-Lebanon Hospital.
Instructions: Review and adapt as appropriate.
Background
- Escherichia coli constituted 91 percent of community-acquired urinary isolates in the past year in BLHC.
- Bacterial resistance to sulfamethoxazole/trimethoprim (SMZ/TMP) and fluoroquinolones has increased.
- Urine culture and susceptibility (C & S) tests are strongly recommended for any therapy changes.
- Modify therapy according to BLHC UTI guidelines.
- Do not use SMZ/TMP as empiric therapy or ciprofloxacin as initial therapy due to high resistance to E. coli.
% Sensitive Urinary Isolates, Community Acquired (2010)
E. Coli | Antibiotics |
---|---|
45 | Ampicillin/sulbactam |
75 | Amoxicillin/clavulanate |
92 | Ceftriaxone |
78 | Cefazolin |
74 | Ciprofloxacin |
87 | Cefuroxime |
94 | Nitrofurantoin |
95 | Piperacillin/tazobactam |
63 | Sulfamethoxazole/trimethoprim |
88 | Gentamicin |
39 | Ampicillin |
Guideline Recommendations
Step 1: Urinalysis
- Urinalysis (UA).
- Urine micro.
- Urine culture:
- Before antibiotics are started.
- For ED patients.
- Inpatients with UTIs.
- All patients with suspected pyelonephritis.
Step 2: Empiric Antibiotics
- Refer to table.
Step 3: Pathogen-Directed Therapy
- With culture and susceptibility results, change antibiotic to pathogen-specific agent.
- Follow up on all discharged patients to provide appropriate therapy based on culture and sensitivity results.
- SMZ/TMP can be used at this point as dictated by the C & S results.
- Reserve fluoroquinolones for pyelonephritis and major systemic infections due to resistance development.
Step 4: Duration
- As important as the therapy itself.
- Excessive use can lead to:
- Adverse reactions.
- Increased antimicrobial resistance.
- Refer to table for specific duration recommendations.
Step 5: Epidemiologic Surveillance
- With time and selective pressure, resistance patterns will change.
- At least once a year, susceptibility patterns will be reassessed and the need to change treatment recommendations evaluated.
Asymptomatic Bacteriuria
- Asymptomatic bacteriuria is defined as isolation of a specific quantitative count of bacteria in an appropriately collected urine specimen from an individual without sign or symptoms of a urinary tract infection.
- Avoiding treatment of asymptomatic bacteriuria is important for reducing the development of antibiotic resistance.
- Treatment of asymptomatic bacteriuria is not appropriate for: women (premenopausal, nonpregnant), diabetics, elderly people, nursing home residents, or patients with spinal cord injury or indwelling urethral catheters.
- Treatment of asymptomatic bacteriuria is appropriate for pregnant women and for patients undergoing urologic procedures in which mucosal bleeding is expected.
Empiric Therapy Regimen
Acute Uncomplicated Cystitis
Antibiotic Recommendations | Caution | Duration | Possible Side Effects (selected) |
---|---|---|---|
Nitrofurantoin (Macrobid) 100 mg twice daily | Do not use if CrCl <60. Do not use for elderly patient >65 years old. Do not use during pregnancy at term (38 to 42 weeks gestation). Caution in cholestatic jaundice and hepatic dysfunction. |
5 days | GI intolerance; Lupus-like reactions; rash Rare: peripheral neuropathy; trigeminal neuralgia pulmonary reactions; hepatitis; hemolytic anemia in G6PD deficiency |
Cefuroxime 250 mg oral q12h | Avoid in penicillin allergy. If CrCl <10mL/min, administer once daily. |
7 days | Anaphylaxis (PCN allergic); diarrhea; other super infections; eosinophilia; positive Coombs test; interstitial nephritis; hemolytic anemia |
Cefpodoxime 100 mg oral q12h | Avoid in penicillin allergy. If CrCl <30mL/min, administer once daily. |
7 days | As above |
Ciprofloxacin 250 mg oral q12h—3rd line therapy due to resistance. If selected, urine culture with followup is recommended. | If CrCl <30mL/min, administer once daily. | 5 days | C. difficile colitis; QTc prolongation; nephritis; tendon rupture; neuropathy |
Acute Uncomplicated Pyelonephritis
Antibiotic Recommendations | Caution | Duration | Possible Side Effects (selected) |
---|---|---|---|
Initial Therapy | |||
Ceftriaxone 1 g IV/IM 1st dose | Avoid in serious, type-I PCN allergy | Initial dose | As above for cefuroxime plus pseudocholelithiasis |
Gentamicin IV 3 mg/kg x1 dose | No adjustment for initial dose needed for renal failure | Initial dose | Renal function |
Followup Therapy—Tailor Therapy to Culture and Sensitivity Report; Otherwise: | |||
Ciprofloxacin 500 mg oral q12h | As above | 7 to 14 days | As above |
Cefuroxime 250 mg oral q12h | As above | 7 to 14 days | As above |
Cefpodoxime 200 mg oral q12h | As above | 7 to 14 days | As above |
References
1. Gupta K, Hooton TM, Naber KG, 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. Clin Infect Dis 2011:52(5):e103-20. Review.
2. Nicolle LE, Bradley S, Colgan R, et al Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54.