Empiric antimicrobial selection for acute complicated urinary tract infection in nonpregnant adults in the outpatient setting

This algorithm reflects our approach to the selection of empiric antimicrobial therapy for nonpregnant patients in the outpatient setting who have an acute complicated UTI. Ultimately, the selection of antimicrobial therapy should be individualized based on severity of illness, individual and community risk factors for resistant pathogens, and specific host factors. Refer to other UpToDate content for discussion of UTI during pregnancy.
Outpatient management is acceptable for patients with mild to moderate illness, including those who can be stabilized with rehydration and initial antimicrobial therapy in an outpatient or emergency room setting and discharged on oral antibiotics with close follow-up. Indications for inpatient management include persistently high fever or pain, marked debility, inability to maintain oral hydration or take oral medications, suspected urinary tract obstruction, and concerns regarding adherence to therapy. If inpatient management is anticipated, refer to other UpToDate content on antimicrobial therapy selection for the inpatient setting.
In addition to antimicrobial therapy, patients who have anatomical or functional urinary tract abnormalities (including neurogenic bladder, indwelling bladder catheters, nephrostomy tubes, urethral stents) may warrant additional management, such as more frequent catheterization to improve urinary flow, exchange of a catheter, and/or urologic or gynecologic consultation.
Doses listed are for patients with normal renal function and may require adjustment in the setting of renal impairment.

ESBL: extended-spectrum beta-lactamase; IM: intramuscular; IV: intravenous; MDR: multidrug-resistant; TMP-SMX: trimethoprim-sulfamethoxazole; UTI: urinary tract infection.

* We consider individuals who have pyuria with only cystitis symptoms to have acute simple cystitis and manage them differently. Fever or systemic symptoms suggest that infection has extended beyond the bladder and is a complicated UTI. The possibility of prostatitis should also be considered in males with urinary and systemic symptoms. The temperature threshold used to determine whether to treat a patient as simple cystitis or complicated UTI is not well defined and should take into account baseline temperature, other potential contributors to an elevated temperature, and the risk of poor outcomes should empiric antimicrobial therapy be inappropriate.

¶ This includes a single antimicrobial dose given for prophylaxis prior to prostate procedures.

Δ A longer duration of therapy may be warranted in patients who have a nidus of infection that cannot be removed. Patients who have worsening symptoms following initiation of antimicrobials, persistent symptoms after 48 to 72 hours of appropriate antimicrobial therapy, or recurrent symptoms within a few weeks of treatment should have additional evaluation including abdominal/pelvic imaging, if not already performed) for factors that might be compromising clinical response.

◊ Patients should be advised about the uncommon but potentially serious musculoskeletal and neurologic adverse effects associated with fluoroquinolones.

§ For outpatients who are more ill (but do not warrant hospitalization), we suggest a single dose of a long-acting parenteral agent prior to the oral regimen if the community prevalence of fluoroquinolone resistance in Escherichia coli is known to be >10 or if a non-fluoroquinolone regimen is used.

¥ Appropriate oral agents to treat complicated UTI include levofloxacin (5 to 7 days), ciprofloxacin (for 5 to 7 days), and TMP-SMX (for 7 days). Beta-lactams (for 7 days) are appropriate if susceptibility is documented and other agents are not feasible.

Graphic 116091 Version 12.0

UpToDate خرید پکیج

Empiric antimicrobial selection for acute complicated urinary tract infection in nonpregnant adults in the outpatient setting

خرید پکیج