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

This algorithm reflects our approach to the selection of empiric antimicrobial therapy for patients hospitalized (or expected to be hospitalized) with 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.
The decision to hospitalize a patient is usually clear in the setting of critical illness or sepsis. Otherwise, general indications for inpatient management include persistently high fever (eg, >101°F/>38.4°C) or pain, marked debility, inability to maintain oral hydration or take oral medications, suspected urinary tract obstruction, and concerns regarding adherence to therapy. If outpatient management is anticipated following therapy in the emergency department, refer to other UpToDate content on antimicrobial therapy selection for the outpatient setting.
In addition to antimicrobial therapy, the possibility of urinary obstruction should be considered and managed, if identified. Patients who have anatomical or functional urinary tract abnormalities (including neurogenic bladder, indwelling bladder catheters, nephrostomy tubes, ureteral 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; FQ: fluoroquinolone; IV: intravenous; MDR: multi-drug resistant; MRSA: methicillin-resistant Staphylococcus aureus; PO: oral; TMP-SMX: trimethoprim sulfamethoxazole; UTI: urinary tract infection; VRE: vancomycin-resistant enterococci.

* 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 versus 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.

¶ Features that should raise suspicion for urinary tract obstruction include a decline in the renal function below baseline, a decline in urine output, or colicky abdominal pain suggestive of nephrolithiasis.

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

◊ Advanced cephalosporin or carbapenem combinations with beta-lactamase inhibitors and the advanced aminoglycoside plazomicin also have activity against some ESBL-producing and, in some cases, MDR Pseudomonas aeruginosa isolates and are effective for acute complicated UTI; however, these should only be used in select cases of highly resistant infections. If carbapenem resistance is suspected based on prior susceptibility testing results, an infectious diseases consult should be obtained.

§ The choice among these agents depends on susceptibility of prior urinary isolates, patient circumstances (allergy or expected tolerability, history of recent antimicrobial use), local community resistance prevalence (if known), drug toxicity and interactions, availability, and cost. If drug-resistant gram-positive organisms are suspected because of previous urinary isolates or other risk factors, vancomycin (for MRSA) or linezolid or daptomycin (for VRE) should be added.

¥ Concern for particular pathogens (eg, because of prior urinary isolates) should further inform antibiotic selection. If Enterococcus species are suspected, piperacillin-tazobactam has activity against these organisms in addition to typical 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. If there is a risk of P. aeruginosa, piperacillin-tazobactam, cefepime, or a fluoroquinolone is an appropriate option.

‡ 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.

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