The following guidelines were prepared by the Alaska Antimicrobial Stewardship Collaborative (A2SC), and are reproduced here as a service to practitioners in the state.
These guidelines have not been reviewed or approved by the Sanford Guide Editorial Board.
General Statements
- Scope of this guideline is limited to immunocompetent adults >18 y/o without history of renal transplant.
- This guideline is intended to aid in the selection of antimicrobial therapy in adult INPATIENTS residing in Alaska who are diagnosed with a urinary tract infection. It is not intended to replace the clinical judgment of the prescribing provider or to be used for those residing outside the State of Alaska.
- Nitrofurantoin is contraindicated for CrCl < 30mL/min and in pregnancy at term (38-42wks).
- Statewide E. coli susceptibility to TMP/SMX is <80% and should be avoided as empiric therapy, but may be considered if confirmed by C&S for complicated UTI or pyelonephritis (2 week duration).
- If patient reports penicillin allergy, inquire about onset and severity of symptoms, as well as prior beta-lactam exposure and update patient medical record. Severe or life-threatening allergic reactions may include: anaphylaxis, angioedema, urticaria, Stevens-Johnson Syndrome (SJS), etc.
- Patients with recurrent UTIs should have empiric therapy selected based upon prior C&S results.
- Chronic antibiotic prophylaxis for most patients with risk factors for recurrent, complicated UTI is NOT typically recommended. Risk of resistance outweighs the slight reduction in infection rate.
Asymptomatic Bacteriuria
Symptoms and/or Risk Factors
- Isolation of a specific quantity of bacteria in an appropriately collected urine specimen (≥105 cfu/mL or from catheter; ≥102 cfu/mL) from an individual WITHOUT signs or symptoms of infection.
Culture & Susceptibility (C&S) Investigation
- Routine C&S is NOT indicated in asymptomatic patients unless screening in pregnancy or prior to urologic procedure with compromise of the urothelial mucosa.
Recommended Treatment and Duration
- Treatment is NOT recommended for patients who fail to meet the below criteria (e.g. pregnancy or those undergoing urologic procedures).
- Pregnant women: (select one option)
- Nitrofurantoin 100mg PO BID x 5d
- ** NOTE: contraindicated at 38-42 weeks gestation
- Cephalexin 500mg PO BID x 5d
- Nitrofurantoin 100mg PO BID x 5d
- Urologic procedure:
- Direct treatment based on pre-procedure screening C&S.
Acute Cystitis
Symptoms and/or Risk Factors
- General symptoms: Acute onset dysuria, frequency or urgency
- Consider deviation from the below recommendations (or consult to ID provider) if any of the following risk factors for multi-drug resistant organisms are present: antibiotic exposure within 90 days, presence of urinary invasive device(s), history of UTI with multi-drug resistant organism.
Culture & Susceptibility (C&S) Investigation
- If patient requires inpatient admission for acute cystitis, acute pyelonephritis, or complicated/catheter associated cystitis, urine C&S are critical in order to optimize therapy.
- Urine cultures should be collected from a midstream void prior to antibiotics or a freshly placed urinary catheter.
Recommended Treatment and Duration
- First Line: (select one option)
- Nitrofurantoin 100mg PO BID x 5d
- Cephalexin 500mg PO BID x 7d
- Second Line:
- Ciprofloxacin 250mg PO BID x 3d
- Fluoroquinolone FDA Safety Alert: Disabling & potentially permanent adverse effects outweigh benefit in cystitis. Only use when no other alternatives exist.
**NOTE: If at risk for STIs w/ symptoms of urethritis, consider screening for chlamydia.
Acute Pyelonephritis
Symptoms and/or Risk Factors
- Upper UTI is frequently associated with general symptoms PLUS back/flank pain, fever & chills.
- Consider deviation from the below recommendations (or consult to ID provider) if any of the following risk factors for multi-drug resistant organisms are present: antibiotic exposure within 90 days, presence of urinary invasive device(s), history of UTI with multi-drug resistant organism.
Culture & Susceptibility (C&S) Investigation
- If patient requires inpatient admission for acute cystitis, acute pyelonephritis, or complicated/catheter associated cystitis, urine C&S are critical in order to optimize therapy.
- Urine cultures should be collected from a midstream void prior to antibiotics or a freshly placed urinary catheter.
Recommended Treatment
- First Line:
- Ceftriaxone 1g IV Q24H
- Second Line:
- Ciprofloxacin 400mg IV Q12H
- Levofloxacin 750mg IV Q24H
**NOTE: Above recommendations are for empiric antimicrobial therapy, tailor maintenance therapy to C&S report.
Duration
- Duration may vary based upon final antibiotic selection.
- Shorter courses (7 days) are reasonable, if symptoms promptly resolve.
- Longer courses (10-14 days) if delayed response, regardless if catheterized or not.
Complicated UTI / Catheter-Associated UTI (CAUTI)
Symptoms and/or Risk Factors
- Complicated UTI: Infection in males or in the presence of an anatomic/functional abnormality (e.g. enlarged prostate, calculi, obstruction, catheter or stent, neurogenic bladder, neutropenia).
- Consider deviation from the below recommendations (or consult to ID provider) if any of the following risk factors for multi-drug resistant organisms are present: antibiotic exposure within 90 days, presence of urinary invasive device(s), history of UTI with multi-drug resistant organism.
Culture & Susceptibility (C&S) Investigation
- If patient requires inpatient admission for acute cystitis, acute pyelonephritis, or complicated/catheter associated cystitis, urine C&S are critical in order to optimize therapy.
- Urine cultures should be collected from a midstream void prior to antibiotics or a freshly placed urinary catheter.
Recommended Treatment
- First Line:
- Ceftriaxone 1g IV Q24H
- Second Line:
- Ciprofloxacin 400mg IV Q12H
- Levofloxacin 750mg IV Q24H
**NOTE: Above recommendations are for empiric antimicrobial therapy, tailor maintenance therapy to C&S report.
Duration
- Duration may vary based upon final antibiotic selection.
- Shorter courses (7 days) are reasonable, if symptoms promptly resolve.
- Longer courses (10-14 days) if delayed response, regardless if catheterized or not.
- If female and < 65 years of age, a 3-day regimen may be considered for CAUTI with catheter removal.
References
- Executive Summary: International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: CID 2011;52(5):561–564.
- Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: CID 2010; 50:625–663.
- IDSA Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. CID 2005; 40:643–54.
- 2015 Updated Beers Criteria
Disclaimer
The Alaska Antimicrobial Stewardship Collaborative (A2SC) and all participating organizations and individuals assume no duty to correct or update these guidelines. Although efforts are made to include material within these guidelines that is accurate and represents the current best practice, there are no representations or warranties regarding errors, omissions, completeness or accuracy of the information provided. These guidelines are not an attempt to practice medicine or provide specific medical advice and should not be used to make a diagnosis or to replace or overrule a qualified health care provider's judgment.
Metadata
Last Updated 10-2018