Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

asymptomatic bacteriuria before urologic procedure

1st line – oral antibiotic therapy

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INITIAL
|
asymptomatic bacteriuria before urologic procedure
1st line – 

oral antibiotic therapy

The purpose of therapy is to temporarily eliminate bacteriuria, because the presence of nonsterile urine during urologic procedures increases the risk of bacteremia and sepsis.

The optimal choice of antibiotics depends on several factors, including the likely local organisms and local resistance patterns, the anatomic site, the type, duration, and invasiveness of procedure being performed. The duration of treatment also varies according to the procedure. A single dose given preoperatively is generally considered appropriate in the majority of uncomplicated procedures.[103]

A urine culture with antibiotic sensitivities obtained several days before the procedure will help guide antibiotic choices. Consult your local protocols for guidance on antibiotic selection and doses.

After the procedure, the antibiotic can be discontinued unless a catheter remains in place.

ACUTE

not severe and tolerating oral therapy

1st line – oral antibiotic therapy

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ACUTE
|
not severe and tolerating oral therapy
1st line – 

oral antibiotic therapy

The choice of initial empiric therapy should be guided by local resistance patterns as well as previous organisms identified from the patient and associated antimicrobial susceptibility testing data in the last 12 months, along with the patient’s antibiotic exposure within the past 3 months.[2][81]​​[82]​​​​

The Infectious Diseases Society of America recommends a four-step approach to account for changing resistance patterns and specific patient needs. The approach specifically states to assess the severity of illness, the risk factors for resistance, any patient-specific considerations, and, if the patient is septic, consider the local antibiogram if available.[1]​

All men should have a urine culture to assure that the initial empiric antibiotic choice is appropriate.

Treatment options include beta-lactams (e.g., amoxicillin/clavulanate, cephalexin), trimethoprim/sulfamethoxazole, and fluoroquinolones (e.g., levofloxacin, ciprofloxacin).[1][2][14]​​​

Risks relate to the specific adverse effects of the antibiotic chosen and general antibiotic complications such as pseudomembranous colitis or induction of resistance.

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[93] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

However, depending on patient characteristics and local resistance patterns, fluoroquinolone antibiotics remain a reasonable first-line choice for treatment of UTI in men due to the higher risk of a complicated course in this patient group.[1][2] Due to high levels of resistance, the European Association of Urology recommends against the use of fluoroquinolones for the empiric treatment of complicated UTI (cUTI) in patients from urology departments or when patients have used fluoroquinolones in the last 6 months.[2] Trimethoprim/sulfamethoxazole may be used first-line in younger men without evidence of cUTI and with consideration to local resistance patterns.

Antibiotic dosing may need to be altered based on the patient's renal status.

Catheter-associated UTI (a cUTI) must be treated with diligence because of the risk of developing bacteremia, but screening for or treatment of asymptomatic bacteriuria in catheterized patients is not recommended.[6][Evidence A][Evidence C] If therapy is initiated, then the catheter should be changed before starting antibiotics.​[2]​​

Treatment for 7-14 days is generally recommended.[2]

Primary options

sulfamethoxazole/trimethoprim: 160 mg orally twice daily for 7-14 days

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OR

amoxicillin/clavulanate: 500 mg orally three times daily for 7-14 days; or 875 mg orally twice daily for 7-14 days

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OR

cephalexin: 500 mg orally twice to four times daily for 7-14 days

OR

levofloxacin: 750 mg orally once daily for 7-14 days

OR

ciprofloxacin: 500 mg orally twice daily for 7-14 days

severe or not tolerating oral therapy

1st line – hospitalization plus intravenous antibiotic therapy

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ACUTE
|
severe or not tolerating oral therapy
1st line – 

hospitalization plus intravenous antibiotic therapy

The choice of initial empiric therapy should be guided by local resistance patterns as well as previous organisms identified from the patient and associated antimicrobial susceptibility testing data in the last 12 months, along with the patient’s antibiotic exposure within the past 3 months.[81]​​​[82]​​​[104]

The Infectious Diseases Society of America recommends a four-step approach to account for changing resistance patterns and specific patient needs. The approach specifically states to assess the severity of illness, the risk factors for resistance, any patient-specific considerations, and, if the patient is septic, consider the local antibiogram if available.[1]​​

All men should have a urine culture to assure that the initial empiric antibiotic choice is appropriate.

Treatment options include beta-lactam antibiotics (e.g., ceftriaxone, ampicillin, imipenem/cilastatin, aztreonam, piperacillin/tazobactam) often in combination with other antibiotics (e.g., aminoglycosides such as gentamicin), and fluoroquinolones (e.g., levofloxacin, ciprofloxacin).[1]​[2][14]​​

In the setting of increasing drug resistance in uropathogens, carbapenems (e.g., imipenem/cilastatin) and novel-broad spectrum antimicrobial agents can be considered in patients with early culture results indicating multidrug-resistant organisms. The choice between these agents should be based on local resistance patterns and on the basis of drug susceptibility results.[1][2]

The following treatments are approved by the Food and Drug Administration (FDA) for use in adults with complicated UTI (cUTI) caused by susceptible organisms who have limited or no alternative options: meropenem/vaborbactam, plazomicin, cefiderocol, and imipenem/cilastatin/relebactam.[94][95][96][97][98][99]

Intravenous antibiotics are continued until the patient is stabilized and can tolerate oral therapy.

Risks relate to the specific adverse effects of the antibiotic chosen and general antibiotic complications, such as pseudomembranous colitis or induction of resistance.

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[93]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

​However, depending on patient characteristics and local resistance patterns, fluoroquinolone antibiotics nevertheless remain a reasonable first-line choice for treatment of UTI in men due to the higher risk of a complicated course in this patient group.[1]​[104]​​

Due to high levels of resistance, the European Association of Urology recommends against the use of fluoroquinolones for the empiric treatment of cUTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months.[104]​​

Dosing may need to be altered based on the patient's renal status, and consideration should be given to the possibility of Pseudomonas infection in catheterized patients.

Catheter-associated UTI (a cUTI) must be treated with diligence because of the risk of developing bacteremia, but screening for or treatment of asymptomatic bacteriuria in catheterized patients is not recommended.[6][Evidence A][Evidence C] If therapy is initiated, then the catheter should be changed before starting antibiotics.​​[104]​​​

Treatment for 7-14 days is generally recommended.[104]​​

Primary options

ceftriaxone: 1-2 g intravenously every 24 hours

OR

ampicillin: 2 g intravenously every 6 hours

and

gentamicin: 1.5 mg/kg intravenously every 8 hours

OR

gentamicin: 1.5 mg/kg intravenously every 8 hours

OR

imipenem/cilastatin: 500 mg intravenously every 6-8 hours

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OR

aztreonam: 1 g intravenously every 8 hours

OR

piperacillin/tazobactam: 3.375 g intravenously every 6 hours

More

OR

meropenem/vaborbactam: 4g intravenously every 8 hours

More

OR

plazomicin: 15 mg/kg intravenously every 24 hours, maximum 7 days treatment

OR

cefiderocol: 2 g intravenously every 8 hours

OR

imipenem/cilastatin/relebactam: 1.25 g intravenously every 6 hours

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OR

levofloxacin: 750 mg intravenously every 24 hours

OR

ciprofloxacin: 400 mg intravenously every 12 hours

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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