ED: Initial Empiric Antimicrobials for Urinary Tract Infections
Condition
Preferred treatment options
Comments
Trimethoprim-Sulfamethoxazole
(TMP-SMX) 1 double-strength
(DS) tablet (160 mg/800 mg)
orally every 12 hours for 3 days
80-85% of acute uncomplicated
cystitis cases are caused by E.
coli followed by Staphylococcus
saprophyticus.
Uncomplicated Cystitis in Women
If recently treated with a specific
antibiotic class, would consider
using an alternative class of
antibiotic. If culture data
available, tailor regimen to the
appropriate antibiotic.
OR
72% of community-acquired E.
coli is susceptible to TMP-SMX.
Cephalexin 250-500 mg every 6
Higher rates of susceptibility
hours for 7 days
seen in patients without history
OR
of antibiotic exposure (e.g.,
Ciprofloxacin 500 mg orally every young healthy women)
12 hours for 3 days
Around 84% of E. coli is
OR
Nitrofurantoin (Macrobid®) 100
mg dose every 12 hours for 7
days
susceptible to ciprofloxacin but
resistance may be higher in the
setting of recent fluoroquinolone
use.
Around 90% of outpatient E. coli
isolates are susceptible to
cephalexin.
>95% of E. coli isolates are
susceptible to nitrofurantoin.
Nitrofurantoin is the most costly
of these agents.
In the case of prior Enterococcus
infections consider using
amoxicillin (500 mg three times a
day for 7 days).
*Please do not use moxifloxacin
for urinary tract infections.
Pyelonephritis in Women
Outpatient therapy
DO NOT USE NITROFURANTOIN FOR UPPER TRACT INFECTIONS
Ciprofloxacin 500 mg orally every In the case of known
12 hours for 7- 14 days
Enterococcus infections consider
using amoxicillin or amoxicillinOR
clavulanate.
Cephalexin 500 mg every 6 hours
for 10-14 days
10/25/10
*Please do not use moxifloxacin
for urinary tract infections.
OR
TMP-SMX 1 DS tablet every 12
hours for 14 days
Inpatient therapy
Ceftriaxone 1-2 g IV every 24
hours
OR
Ceftriaxone has activity against
94% of E. coli isolates. It does
not cover Enterococcus species.
Ciprofloxacin 500 mg orally (or
400 mg IV) every 12 hours
In the case of prior Enterococcus
infections consider using
ampicillin or ampicillinsulbactam.
Cephalexin 250-500 mg orally
every 6 hours for 7 days
Fluoroquinolones should be
avoided in pregnancy.
OR
Pregnant women should have a
follow-up urine culture
performed one to two weeks
after treatment to ensure that
bacteriuria has been eradicated.
Pregnant Women
Cystitis – treat as outpatients as
long as they do not have
symptoms suggestive of
pyelonephritis
Have a low threshold for
hospitalization
Acute pyelonephritis
Nitrofurantoin (Macrobid®) 100
mg dose every 12 hours for 7
days
Ceftriaxone 1-2 g IV every 24
hours for 10-14 days
Men
Urethritis, lower tract infection
For men < 40 years old, consider
STD testing and treatment
≥40 years old E. coli is the most
common uropathogen
DO NOT USE NITROFURANTOIN OR MOXIFLOXACIN
Ciprofloxacin 500 mg orally every Urethritis should be strongly
12 hours for 7 days
considered in sexually active
men. Examination for penile
OR
ulcerations and urethral
Trimethoprim-Sulfamethoxazole discharge and diagnostic tests
(TMP-SMX) 1 double-strength
for Neisseria gonorrhoeae and
(DS) tablet (160 mg/800 mg)
Chlamydia trachomatis are
orally every 12 hours for 7 days
warranted.
Urinary DNA probe
recommended please use
appropriate kit (not swab).
Acute pyelonephritis
Ciprofloxacin 500 mg orally (or
400 mg IV) every 12 hours for 714 days
OR
10/25/10
Any man presenting with
pyelonephritis should have a
complete urologic evaluation to
determine causative factors.
Trimethoprim-Sulfamethoxazole
(TMP-SMX) 1 double-strength
(DS) tablet (160 mg/800 mg)
orally every 12 hours for 7-14
days
Prostatitis
Acute prostatitis can manifest as
frequency, dysuria, and difficulty
urinating with fever and a tender
prostate on exam
Ciprofloxacin 500 mg orally every In the presence of urinary
12 hours for 4 weeks
retention or evidence of
obstruction, please consult
OR
urology.
Trimethoprim-Sulfamethoxazole
Fluoroquinolone use in the
(TMP-SMX) 1 double-strength
elderly may lead to neurologic
(DS) tablet (160 mg/800 mg)
symptoms, patients and/or
orally every 12 hours for 4-6
caregivers should be instructed
weeks
to monitor for signs and
symptoms especially with
prolonged courses.
Healthcare-associated and/or catheter-associated Urinary Tract Infections
Catheter-associated UTI patient
being discharged from ER
Remove catheter if not
indicated.
Use prior culture data to guide
therapy.
Patient should have signs and
symptoms of a urinary tract
infection (e.g., fever, chills,
suprapubic tenderness, altered
mental status)
If catheter in place ≥ 2 weeks
and remains indicated, it should
be replaced. Obtain urinalysis
and urinary culture from freshly
placed catheter prior to initiation
of antibiotics.
Fluoroquinolone use in the
elderly may lead to neurologic
symptoms, patients and/or
caregivers should be instructed
to monitor for signs and
symptoms especially with
prolonged courses.
DO NOT TREAT
AYSYMPTOMATIC PYURIA OR
BACTERIURIA
If no prior exposure to
fluoroquinolones, ciprofloxacin
500 mg orally every 12 hours for
7-14 days depending on
symptom resolution.
Alternatives include:
Trimethoprim-Sulfamethoxazole
(TMP-SMX) 1 double-strength
(DS) tablet (160 mg/800 mg)
orally every 12 hours for 7-14
days
10/25/10
Catheter-associated UTI, patient
being admitted with no prior
culture data
Patient should have signs and
symptoms of a urinary tract
infection (e.g., fever, chills,
suprapubic tenderness, altered
mental status)
DO NOT TREAT
AYSYMPTOMATIC PYURIA OR
BACTERIURIA
Remove catheter if not
indicated.
Use prior culture data to guide
therapy.
If catheter in place ≥ 2 weeks
and remains indicated, it should
be replaced. Urinalysis and
urinary culture obtained from
freshly placed catheter prior to
initiation of antibiotics.
Ceftriaxone 1-2 g IV every 24
hours
OR
If severe β-lactam allergy:
Ciprofloxacin 500 mg (400 mg IV)
every 12 hours
Healthcare-associated UTI
patient with signs and
symptoms of SIRS or urosepsis
Please draw 2 sets of blood
cultures
Remove catheter if not
indicated.
Please use prior culture data to
guide empiric therapy.
If catheter in place ≥ 2 weeks
and remains indicated, it should
be replaced. Obtain urinalysis
and urinary culture from freshly
placed catheter prior to initiation
of antibiotics.
Cefepime 1-2 gram IV every 12
hours
If severe β-lactam allergy:
Aztreonam 1-2 grams IV every 812 hours
Renal Transplant Recipient
1. N Engl J Med. 2003; 349: 259-66
2. Urology Clinic North Am. 2008; 5: 1-12
3. Am Fam Physician 2010; 81: 783-8
4. Clin Infect Dis. 2010; 50: 625-63
10/25/10
Please call Renal Transplant
Service pager 5595 and/or
Transplant ID 8678