UTI Treatment Considerations

Garrett Jarboe, PharmD

PGY-1 Pharmacy Resident
IU Health Ball Memorial Hospital
UTI Background
•Presence of micro-
organisms, and possible
inflammation, within the
urinary tract
• Kidney, ureters, bladder,
and urethra

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Definitions
Uncomplicated: UTI without underlying renal or neurologic disease
Complicated: UTI with underlying structural, medical, or neurologic factor
increasing risk
Pyelonephritis, male, diabetes, pregnancy, hospital acquired, renal failure,
obstruction, catheter, etc.
Recurrent: > 3 symptomatic UTIs within 12 months following clinical
therapy
Reinfection: recurrent UTI caused by a different pathogen at any time
Relapse: recurrent UTI caused by the same species causing original UTI
within 2 weeks after therapy
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Classification

UTI

Upper Lower

Pyelonephriti Renal Perirenal

Cystitis Prostatitis Urethritis
s Abscess Abscess

Acute,
Chronic,
Interstitial
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Etiology
Acute uncomplicated
80% of cases: Escherichia coli
20% of cases:
Gram negative enteric bacteria:
⎻Klebsiella spp.
⎻Proteus spp.
 Gram positive cocci:
⎻Streptococcus faecalis
S. saprophyticus is usually restricted to young sexually active women
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Etiology
 Complicated
 Bacteria
 Pseudomonas aeruginosa
 Enterobacter spp.
 Serratia spp.
 Viruses:
 Rubella
 Mumps
 HIV
 Protozoa
 T. vaginalis
 S. haematobium
 Fungi
 Candida spp.
 Histoplasma capsulatum 6
To Treat or Not to Treat
Symptomatic UTI: Treat with antibiotic therapy
Asymptomatic UTI: No treatment required except if:
Children
Pregnancy
Obstructive structural abnormalities

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The Ideal Antibiotic for UTI

Adequate coverage of E. coli

Short duration of therapy
Adequate concentration in the urine
Blood concentration important for pyelonephritis
Low resistance
Cost effective
Low adverse effects
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Uncomplicated UTI Treatment
 Primary
 Nitrofurantoin monohydrate/macrocrystals 100 mg PO BID with food X 5 days
 Sulfamethoxazole/trimethoprim 800 mg/160 mg PO BID X 3 days
⎻Increasing resistance
 Fosfomycin 3 gm PO X 1 dose
 Alternatives
 Fluoroquinolones (ofloxacin, levofloxacin, ciprofloxacin) X 3 days
 Beta lactams (amoxicillin/clavulanate, cefdinir, cefaclor, cefpodoxime, cephalexin)

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Complicated UTI Treatment
Nitrofurantoin 100 mg PO BID with food X 7 days
Fosfomycin 3 gm PO every 3 days X 3 doses
Sulfamethoxazole/trimethoprim 800 mg/160 mg PO BID X 7-10 days
Beta-lactams
Ceftriaxone 1 gm IM once
Amoxicillin/clavulanate 875 mg PO BID X 10-14 days
Cefdinir 300 mg PO BID X 10-14 days
Fluoroquinolones
Preferred if high-risk of MDR organisms
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Pyelonephritis
• Sulfamethoxazole/trimethoprim 800
mg/160 mg PO BID X 14 days
• Ciprofloxacin 500 mg PO BID X 7 days
• Levofloxacin 750 mg PO daily X 7 days
• Ceftriaxone 1 gm IV Q24H X 10-14 days

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Hospitalized
• No risk factors for MDR gram-negatives
• Ceftriaxone 1 gm IV daily
• Piperacillin-tazobactam 3.375 gm
IV Q6H
• Ciprofloxacin or levofloxacin PO
• Risk factors for MDR gram-negatives
• Piperacillin-tazobactam 3.375 gm
IV Q6H
• Imipenem 500 mg IV Q6H
• Meropenem 1 gm IV Q8H
• Risk factors for MDR gram-positives
• Vancomycin
• Linezolid
• Daptomycin 12
 Adverse effects:
• Hypersensitivity
• Pneumonitis
• GI upset
• Hemolytic anemia

Contraindications:
Nitrofurantoin
• Renal failure
• Pregnancy

No systemic effects, so not for suspected

pyelonephritis

Caution if CrCl < 30 mL/min

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 Adverse effects:
• SJS
• Dermatitis
• Angioedema
Sulfamethoxazole- • GI upset
• Agranulocytosis
Trimethoprim
Contraindications
• Hypersensitivity to sulfa
• Megaloblastic anemia
Avoid in 3rd trimester of pregnancy

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 Adverse effects: 
• Headache
Fosfomycin • Rash
• GI upset

No systemic effects, so
no use for pyelonephritis
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 Adverse effects:
• Rash
• GI upset
• Renal dysfunction
Beta-Lactams • Colitis
• Lethargy
• Anemia
Contraindications:
• Penicillin hypersensitivity

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 Adverse effects
• Peripheral neuropathy
• Rhabdomyolysis
Fluoroquinolones
• SJS
• Hemolytic anemia
• Tendon rupture
• GI upset
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Considerations

Pregnancy
Use amoxicillin, cephalexin, or nitrofurantoin for 7 days
⎻No nitrofurantoin in 3rd trimester
⎻Avoid tetracyclines, SMX/TMP, fluoroquinolones
Catheter associated UTI
Treat only if symptomatic
Remove and replace catheter
Treat for 7-14 days according to culture report
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Considerations

§Elderly
§Avoid fluoroquinolone use
§Dose reductions for impaired renal function: Bactrim,
ciprofloxacin and levofloxacin
⎻Nitrofurantoin

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