Urinary Tract Infection in Adult Patients: Treatment ...

Urinary Tract Infection in Adult Patients:
Diagnosis and Management

For Pyelonepritis management and treatment refer to
“Acute Pyelonephritis in Adult Patients - Diagnosis and Management”

Suspected Urinary Tract Infection* OR Preoperative Surgical Screening

• Fever ≥ 100.4 ˚F • Consider only in the instance of high-risk

• Costovertebral angle tenderness surgery including:

• Shaking chills/rigors • Cardiac surgery

• New onset of delirium • Neurosurgery

• Dysuria • Urologic surgery/procedures

• Urinary urgency and/or frequency

• Suprapubic or flank pain

* Patients with indwelling catheter may be asymptomatic

If suspected pyelonephritis refer to respective • If indwelling urinary catheter present for > 3 days,
guideline for “Acute Pyelonephritis in Adult recommend removal/replacement PRIOR to
Patients – Diagnosis and Management” collecting sample.

• Ascertain need for indwelling catheter prior to
replacement (refer to Urinary Urethral Catheter
Removal Protocol)

Order appropriate urine testing based on criteria "A" vs "B"

A. Urinalysis with Reflex to Culture for General B. Urinalysis AND Culture for PregnantA, Transplant,
Population
Immunocompromised, Immunosuppressed, or
Lab will reflex to culture if urinalysis meets any
ONE of the following: NICU meeting one or more of a following:
• ≥ Moderate Leukocyte Esterase • Neutropenia with ANC ≤ 500 cells/uL
• WBC > 5 • HIV with a CD4 count < 200 cells/mm3
• Bacteria present with squamous cells ≤ 2+ • Receipt of chemotherapy within previous 2
• Nitrite positive with squamous cells ≤ 2+
weeks for active malignancy
• Administration of immunosuppressive agents

(azathioprine, cyclosporine, tacrolimus,

sirolimus, and mycophenolate)
• Administration of corticosteroid dose equivalent

to 20 mg prednisone for at least 1 month

Asymptomatic patients without
indwelling urinary catheters
• Antimicrobial therapy is NOT recommeded

Treatment Considerations for those with Symptoms, Positive Urinalysis, at High-Risk
• If catheterized, replace indwelling catheter
• Begin empiric antimicrobial therapy (See Treatment Considerations - Step 1)
• See Steps 2 - 3 for antimicrobial dosing recommendations and treatment duration guidance.
• Evaluate culture and susceptibilities when available and tailor antimicrobial therapy accordingly

A Pregnant women should be screened for bacteriuria early in pregnancy and treated with antimicrobial for 10 days if culture
results are positive.

2

Empiric Treatment Considerations

1. If no cultures/susceptibilities available, consider the following empiric options in order of preference:

a. Cephalexin (Keflex®) PO
b. Ceftriaxone (Rocephin®) IVPB if enteral access not available or concern for altered absorption
c. Nitrofurantoin (Macrobid®)- DO NOT USE IF Creatinine Clearance (CrCl) < 60 mL//min
d. Sulfamethoxazole / trimethoprim (Bactrim DS®)
e. Levofloxacin (Levaquin®) – utilize PO formulation if enteral access is available and there is no concern for altered

absorption

2. Determine severity of UTI – this will determine duration of therapy

Severity Definition

Uncomplicated  Patient with a structurally and neurologically normal urinary tract
o Usually only applicable to premenopausal women

Complicated  Patient with a functional or anatomical abnormality of the urinary tract and usually

includes men and pregnant women. Other examples include:
o Urinary catheter
o GU tract obstruction

3. Commonly used antibiotic dosing recommendations based on renal function:

Renal Function Cephalexin Ceftriaxone Nitrofurantoin SMX/TMP Levofloxacin
CrCl >50 500 mg PO q12h (PO/IV)
CrCl 30-50 CrCl ≥ 60:100 q12h 1 DS tab (800/160)
q12h 250 mg q24h

CrCl 10-29 1 gm IV DO NOT USE 1 DS tab (800/160) 250 mg q48h
q24h q24h 250 mg q24h
iHD/CrCl<10‡ 500 mg PO q24h
500 mg PO q12h 3 days 1 SS tab (400/80)
CRRT# q12h
Recommended 3 days
5 days 3 days 3 days
Duration*
Uncomplicated

Complicated 10 days 10 days 10 days 10 days 10 days

* Duration should guided by the specific clinical situation and the response to therapy
‡ iHD: Intermittent Hemodialysis
# CRRT: Continuous Renal Replacement Therapy

Clinical Considerations

The following pathogens are not considered common urinary pathogens:
 Candida species- In most patients, isolation of Candida represents colonization. When possible, consider the
removal of catheter as this may resolve the candiduria. The IDSA recommends
treatment of candiduria only in the following: symptomatic patients, patients with neutropenia, infants with low
birth weight, patients with renal allografts, and patients who will undergo a urologic procedure. If treatment is
indicated, then treat for 7-14 days.1

 Enterococcus- Often represents colonization or contamination. Consider not treating unless the patient is
symptomatic and corresponding urinalysis shows inflammation.

 Staphylococcus aureus- If isolated from the urine, unless there are other indicators of contamination then
consider obtaining blood cultures. Often Staphylococcal bacteruria is secondary to bacteremia.

 Gardnerella vaginalis- Gardnerella is the most common cause of bacterial vaginosis (BV), but can also cause
UTI. If it grows in significant numbers in culture and the corresponding urinanalysis shows inflammation, then
treatment with metronidazole 500 mg PO/IV BID for 7 days is indicated.

3

References Protocols

1. Pappas PG, et al. Infectious Diseases Society  OSUWMC Urinary Urethral Catheter
of America. Clinical practice guidelines for the Removal Protocol
management of candidiasis: 2009 update by
the Infectious Diseases Society of America. Guideline Authors
Clin Infect Dis. 2009 Mar 1;48(5):503-35.
 Erik Abel, PharmD, BCPS
2. Nicolle LE, et al; Infectious Diseases Society  Pam Burcham, PharmD, BCPS
of America; American Society of Nephrology;  Karri Bauer, PharmD, BCPS
American Geriatric Society. Infectious  Sajni Patel, PharmD
Diseases Society of America guidelines for  Erica Reed, PharmD, BCPS
the diagnosis and treatment of asymptomatic  Jessica Elefritz, PharmD
bacteriuria in adults. Clin Infect Dis. 2005  Amy Gewirtz, MD
Mar 1;40(5):643-54.  Harrison Weed, MD
 Jeffery Caterino, MD
3. Hooton TM, et al. Infectious Diseases Society  Kurt Stevenson, MD
of America. Diagnosis, prevention, and  Julie Mangino, MD
treatment of catheter-associated urinary tract  Christina Liscynesky, MD
infection in adults: 2009 International Clinical
Practice Guidelines from the Infectious Reviewed through P&T Antibiotic Subcommittee
Diseases Society of America. Clin Infect Dis.
2010 Mar 1;50(5):625-63. Guideline Approved

4. Gupta K, et al. Infectious Diseases Society of February 26, 2014. First Edition
America; European Society for Microbiology
and Infectious Diseases. International clinical Disclaimer
practice guidelines for the treatment of acute
uncomplicated cystitis and pyelonephritis in Clinical practice guidelines and algorithms at The
women: A 2010 update by the Infectious Ohio State University Wexner Medical Center
Diseases Society of America and the (OSUWMC) are standards that are intended to
European Society for Microbiology and provide general guidance to clinicians. Patient choice
Infectious Diseases. Clin Infect Dis. 2011 and clinician judgment must remain central to the
Mar 1;52(5):e103-20. selection of diagnostic tests and therapy. OSUWMC’s
guidelines and algorithms are reviewed periodically
5. Centers for Disease Control and Prevention. for consistency with new evidence; however, new
Surveillance for Urinary Tract Infections. developments may not be represented.
http://www.cdc.gov/nhsn/acute-care-
hospital/CAUTI/index.html. Accessed Feb 18, Copyright © 2014, The Ohio State University Wexner
2014. Medical Center. No part of this publication may be
reproduced in any form without permission in writing
Quality Measures from The Ohio State University Wexner Medical
Center.
 Number of inpatients who receive treatment
based on a negative UA

 Percent of inpatients with confirmed UTI who
receive one of the following medications:
o cephalexin (Keflex®)
o ceftriaxone (Rocephin®)
o nitrofurantoin (Macrobid®)
o sulfamethoxazole / trimethoprim
(Bactrim®)
o levofloxacin (Levaquin®)

 Distribution of various tests to work up UTIs
o Urinalysis total with reflex to culture
o Urinalysis total AND culture

 Number of urine cultures orders without
preceding or concomitant UA within 24 hours

 CAUTI Rate