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Empiric antimicrobial agent selection for acute complicated urinary tract infection in nonpregnant adults

Empiric antimicrobial agent selection for acute complicated urinary tract infection in nonpregnant adults
Patient population Individual risk for MDR?* Empiric regimens Comments
Hospitalized with:
  • Critical illness warranting intensive care (eg, severe sepsis) or
  • Acute urinary tract obstruction
 N/A In regions where community prevalence of ESBL-producing organisms is high or uncertain:
  • An antipseudomonal carbapenem:
    • Imipenem 500 mg IV every 6 hours infused over 3 hours or
    • Meropenem 1 to 2 g IV every 8 hours infused over 3 hours
  • plus
  • Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours with or without a loading dose
  • The rationale for broad coverage is the high risk of adverse outcomes with insufficient antimicrobial therapy.
  • When broad-spectrum regimens are used empirically, it is important to tailor the regimen if culture and susceptibility testing indicate that a narrower agent would be active.
In regions where community prevalence of ESBL-producing organisms is low (eg, <10%):
  • Select a regimen based on individual MDR risk, as listed for "Other hospitalized patients"
Other hospitalized patients No MDR risk
  • Ceftriaxone 1 g IV once daily
  • Alternatives:
    • Levofloxacin 750 mg IV or orally daily
    • Ciprofloxacin 400 mg IV twice daily
    • Ciprofloxacin 500 mg orally twice daily
    • Ciprofloxacin extended-release 1000 mg orally once daily
 Concern for particular pathogens (eg, because of prior isolates) should further inform antibiotic selection:
  • If Enterococcus is suspected (eg, based on prior isolates), piperacillin-tazobactam is active against this and gram-negative pathogens.
  • If drug-resistant gram-positive organisms are suspected, vancomycin (for MRSA) or linezolid or daptomycin (for VRE) should be added to the gram-negative agent (eg, ceftriaxone).
  • If Pseudomonas is suspected, piperacillin-tazobactam, cefepime, or a fluoroquinolone are appropriate options.
Yes MDR risk
  • Piperacillin-tazobactam 3.375 g IV every 6 hours or
  • Cefepime 2 g IV every 8 to 12 hours or
  • An antipseudomonal carbapenem:
    • Imipenem 500 mg IV every 6 hours infused over 3 hours or
    • Meropenem 1 to 2 g IV every 8 hours infused over 3 hours
  • If VRE or MRSA are suspected (eg, based on prior isolates), vancomycin (for MRSA) or daptomycin or linezolid (for VRE) is added.
  • If the patient has a history of urinary tract infection with an ESBL-producing organism in the prior three months and is more severely ill, we favor a carbapenem.
Outpatients No MDR risk, and no concerns with fluoroquinolones (eg, at low risk for adverse effects)
  • Ciprofloxacin 500 mg orally twice daily for 5 to 7 days or
  • Ciprofloxacin extended-release 1000 mg orally once daily for 5 to 7 days or
  • Levofloxacin 750 mg orally once daily for 5 to 7 days
  • For patients with significant symptoms (but no indications for 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 usedΔ:
    • Ceftriaxone 1 g IV or IM once
    • Ertapenem 1 g IV or IM once
    • Gentamicin 5 mg/kg IV or IM once
    • Tobramycin 5 mg/kg IV or IM once
No MDR risk, but with concerns with fluoroquinolones (eg, at risk for adverse effects)
  • TMP-SMX one double-strength tablet orally twice daily for 7 days or
  • Amoxicillin-clavulanate 875 mg orally twice daily for 7 days or
  • Cefpodoxime 200 mg orally twice daily for 7 days or
  • Cefixime 400 mg orally once daily for 7 days or
  • Cefuroxime 500 mg orally twice daily for 7 days or
  • Cefadroxil 1 g orally twice daily for 7 days
Yes MDR risk
  • Ertapenem 1 g IV or IM once
  • Followed by:
    • Ciprofloxacin 500 to 750 mg orally twice daily for 5 to 7 days or
    • Ciprofloxacin extended-release 1000 mg orally once daily for 5 to 7 days or
    • Levofloxacin 750 mg orally daily for 5 to 7 days
  • If the patient cannot take a fluoroquinolone or has high risk for fluoroquinolone resistance (fluoroquinolone-resistant isolate or fluoroquinolone use in prior 3 months):
    • Ertapenem 1 g IV or IM once daily until cultures and susceptibility testing return
These antibiotic regimens represent our approach to empiric treatment for acute complicated UTI in nonpregnant individuals. Once culture and susceptibility testing results are available, the regimen should be tailored to those results. If feasible, an antibiotic with a narrow spectrum of activity should be chosen to complete the antibiotic course. Refer to other UpToDate content for discussion of UTI during pregnancy.

IM: intramuscular; IV: intravenous; MDR: multidrug resistance; MRSA: methicillin-resistant Staphylococcus aureus; TMP-SMX: trimethoprim-sulfamethoxazole; UTI: urinary tract infection; VRE: vancomycin-resistant Enterococcus.

* Risk factors for MDR gram-negative UTIs include any one of the following in the prior 3 months:

  • An MDR, gram-negative urinary isolate, including a fluoroquinolone-resistant Pseudomonas urinary isolate
  • Inpatient stay at a health care facility (eg, hospital, nursing home, long-term acute care facility)
  • Use of a fluoroquinolone, TMP-SMX, or broad-spectrum beta-lactam (eg, third- or later-generation cephalosporin)
  • Travel to parts of the world with high rates of MDR organisms

¶ We reserve the higher doses in the range (eg, cefepime 2 g every 8 hours and meropenem 2 g every 8 hours) for patients who have prior history of MDR isolates with resistance to other beta-lactams.

Δ An alternative for those who are systemically ill or are at risk for more severe illness is to continue the parenteral agent until culture and susceptibility testing results can guide selection of an appropriate oral agent.

Graphic 131022 Version 10.0

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