Sandbox Urinary tract infection medical therapy

Urinary Tract Infection Microchapters
Patient Information
Overview
Classification Pyelonephritis Cystitis Prostatitis Urethritis Asymptomatic bacteriuria
Causes
Differential Diagnosis
Treatment

Main articles: Cystitis medical therapy and Pyelonephritis medical therapy

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

Medical Therapy

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.

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

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.

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).