Complicated UTI

• UTI with systemic symptoms: fever, chills, fatigue; flank pain, CVA tenderness.
  • In men, consider prostatitis, especially if recurrent cystitis symptoms, or pelvic/perineal pain.
    • Digital Rectal Examination warranted
    • Please refer to UTI Special Circumstances – UTI in Men
•  May develop sepsis or renal abscess.
  • Risk factors include diabetes, urinary tract obstruction.
• Perform both urinalysis (Urine dipstick and/or microscopy) and urine culture and sensitivity (urine gram stain can also be helpful).
  • Pyuria and bacteriuria support diagnosis (+/- hematuria)
  • See UTI Diagnostic Approach
• Other investigations include:
  • Blood cultures if sepsis suspected
  • Pregnancy testing if appropriate
  • Imaging performed if:
    • Severe illness (e. sepsis)
    • No improvement with antibiotic therapy
    • Suspicious for urinary tract obstruction, renal abscess
    • CT is first choice (U/S if concern for radiation exposure)
• Microbiology:
  • E. coli most common, then:
    • Klebsiella, Proteus
    • Pseudomonas (risk factors: healthcare exposures, instrumentation)
    • Enterococci
    • MSSA, MRSA
  • Multi-drug resistant (MDR) organism risk factors:

Adapted from UpToDate: Acute simple cystitis in women.

• • Note: E. coli sequence type 131 (ST 131) is a major global cause of UTIs with ESBL and fluoroquinolone resistance.

Management Considerations¹:

• Empiric antibiotics:
  • Initiate early.
  • Use regional/institutional antibiogram (use Spectrum App) to help with antibiotic selection.
• Consult urology if anatomic/functional abnormalities.
  • Consider obtaining appropriate imaging.

Empiric Antibiotics¹:

• Obtain urine gram stain, culture and sensitivity.
• Inpatient:
  • If critically ill, not improving on antibiotics, or urinary tract obstruction:
    • Cover for ESBL organisms and Pseudomonas
      • Antipseudomonal carbapenems
        • Imipenem 500 mg IV q 6h
        • Meropenem 1 gram IV q 8h
    •  Cover for MRSA
      •  Vancomycin:
        • 15 mg/kg/dose (usual maximum: 2 g/dose initially) q 12h is a usual starting dose in most nonobese patients with normal renal function.
      • Alternatives:
        • Daptomycin**
        • 6 mg/kg IV q 24h
          • Linezolid**
          • 600 mg IV q 12h
          • **Note: Daptomycin or Linezolid can also cover for vancomycin-resistant Enterococcus (VRE).
    • Obtain ID consult if carbapenem resistance from prior susceptibility result.
    • Note: In communities where prevalence of MDR is low, narrower spectrum regimens are an option.
  • Non-critically ill or no concern for urinary tract obstruction:
    • No risk factors for MDR gram negative organism:
      • Treatment options:
        • Ceftriaxone 1 gram IV q 24h
        • Piperacillin-tazobactam 3.375 grams IV q 6h
        • Oral or parenteral fluoroquinolones (ciprofloxacin or levofloxacin).
          • No previous cultures resistant to fluoroquinolones in last three months.
          • Community prevalence of E. coli fluoroquinolone resistance 10%.
        • Options:
          • Ciprofloxacin
            • Oral: 500 mg q 12h x 5-7 days
            • Oral: extended release: 1,000 mg q 24 h x 5-7 days
            • IV: 400 mg q 12h x 5-7 days
          • Levofloxacin
            • Oral: 750 mg q 24h x 5-7 d
            • IV: 750 mg q 24h x 5-7 d
        • If suspect Enterococcus or Staphyloccus, piperacillin-tazobactam preferred.
        • If concern for Pseudomonas aeruginosa, use either:
          • Piperacillin-tazobactam 4.5 grams IV q 6h (note: this is a higher dose than indicated above)
          • Fluoroquinolone
          • Cefepime 2 grams IV q 8h
          • Ceftazidime 2 grams IV q 8h
        •  If concern for drug resistant gram positive, add either:
          • Vancomycin 15 mg/kg IV q 12h for MRSA
          • Linezolid 600 mg IV or PO q 12h for VRE
          • Daptomycin 6 mg/kg IV q 24h for VRE
  • 1 or more risk factors for MDR gram negative organism:
    • Cover for ESBL organisms and Pseudomonas
      • Antipseudomonal carbapenem
        • Imipenem 500 mg IV q 6h
        • Meropenem 1 gram IV q 8h
    • If Enterococcus species or MRSA are suspected, add either:
      • Vancomycin 15 mg/kg IV q 12h for MRSA
      • Linezolid 600 mg IV or PO q 12h for VRE
      • Daptomycin 6 mg/kg IV q 24h for VRE

• Outpatient:
  • For non-critically ill patients appropriate for outpatient management with oral antibiotics.
    • Low risk for MDR infection:
      • Fluoroquinolones (PO):
        • Ciprofloxacin 500 mg q 12h x 5-7d
        • Ciprofloxacin 1000 mg extended release q 24h x 5-7d
        • Levofloxacin 750 mg q 24h x 5-7d
        • Note:If E.coli resistance >10%, use single dose IV/IM prior to oral fluoroquinolone.
          • IV/IM options:
            • Ceftriaxone 1 gram (first line)
            • Ertapenem 1 gram (second line)
            • Gentamicin or tobramycin 5 mg/kg (if either above choices cannot be used)
          • Oral options:
            • Ciprofloxacin 500 mg q 12h x 5-7d
            • Ciprofloxacin 1000 mg extended release q 24h x 5-7d
            • Levofloxacin 750 mg q 24h x 5-7d
      • Non-fluoroquinolones:
        • For patients with contraindications to fluoroquinolones
        • Single dose IV/IM followed by oral non-fluoroquinolone:
          • IV/IM options:
            • Ceftriaxone 1 gram (first line)
            • Ertapenem 1 gram (second line)
            • Gentamicin or tobramycin5 mg/kg (if either above choices cannot be used)
          • Oral options:
            • Trimethoprim-sulfamethoxazole double-strength (160 mg/800 mg) tablet BID x 7-10 days
            • Amoxicillin-clavulanate 875 mg BID x 10-14 days
            • Cefadroxil 1 g BID x 10-14 days
        •  Note: If concerned for more serious infection, continue IV antibiotics until urine culture and susceptibility results
    • High risk MDR infection:
      • Initial dose of ertapenem 1 gram IV/IM, followed by fluoroquinolone (if no contraindications, no prior 3 month history of use or documented resistance). See above PO doses.
      • If unable to take fluoroquinolones, recommend continuing ertapenem 1 gram IV/IM once daily, until urine culture and susceptibility results.

Directed Antibiotic Therapy¹:

• • Use results of urine culture susceptibility to narrow empiric antibiotics, if possible.
  • Switch from IV to PO with symptom improvement.
    • In Complicated UTI, acceptable PO antibiotics include:
      • levofloxacin 750 mg once daily x 5-7d
      • ciprofloxacin 500 mg BID x 5-7d
      • ciprofloxacin 1000 extended release once daily x 5-7d
      • trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet BID x 7-10d
      • Consider oral beta-lactams if there is susceptibility and other antibiotics not feasible.
      • *Use of nitrofurantoinand fosfomycin should be avoided – do not achieve appropriate tissue concentrations outside of bladder.
    • *Duration of antibiotics should also be dependent on clinical response.

• Sepsis
• Unable to tolerate oral medications or oral hydration
• Suspected urinary tract obstruction
• Poor patient adherence

• Able to stabilize patient with rehydration and antibiotics in ED
• Able to discharge home on oral antibiotics
• Patient able to have close follow-up

• Patient’s treated in outpatient setting need follow up in 24H
• If no improvement or worsening symptoms or if recurrent symptoms after treatment¹
  • Abdo/Pelvis imaging (generally with CT)
  • Repeat urine culture and susceptibility
    • If other causative organisms found, tailor treatment to that
  • Note^1,3: if hematuria on initial presentation, repeat urinalysis in approximately 6 weeks following completion of antibiotics to evaluate for persistent hematuria

1. Hooton TM, Gupta K. Acute complicated urinary tract infection (including pyelonephritis) in adults. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2020.

   
   

2. Spectrum App

   
   

3. Kurtz M et al. Etiology and evaluation of hematuria in adults. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2020.