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 adults>18 y/o without signs of severe physiologic disturbance. This guideline should not be used for patients who are immunocompromised or kidney transplant recipients.
  • This guideline is intended to aid in the selection of antimicrobial therapy in adult OUTPATIENTS residing in Alaska who present 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 1st line for most patients without symptoms of pyelonephritis. 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).
  • For ESBL (Extended Spectrum Beta-lactamase) producing organisms, treat according to reported susceptibility with nitrofurantoin, TMP/SMX or ciprofloxacin. If resistant to all tested antibiotics or multiple allergies, consult Infectious Diseases for potential alternatives. ESBL pyelonephritis may require inpatient admission and/or IV antibiotics.
  • 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.
  • 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.
  • Treatment is NOT recommended for patients who do not 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
  • 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
  • Risk factors for resistance:
    • Antibiotic exposure within 90d
    • Hospitalization within 90d
    • Presence of invasive device(s)

Culture & Susceptibility (C&S) Investigation

  • Routine C&S is NOT indicated unless risk factor(s) for resistance exist; consider if prescribing 2nd line therapy
  • 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 treatment for chlamydia.

Acute Pyelonephritis

Symptoms and/or Risk Factors

  • Upper UTI is frequently associated with general symptoms PLUS back/flank pain, fever & chills.

Culture & Susceptibility (C&S) Investigation

  • 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.
  • First Line:
    • Ceftriaxone 1g IM/IV x 1 dose
    • If severe or life-threatening beta-lactam allergy, consider Gentamicin 5mg/kg IM/IV x 1 dose

Followed by:

  • First line:
    • Cephalexin 1g PO TID x 10-14d
  • Second line:
    • Ciprofloxacin 500mg PO BID x 7d

Tailor maintenance therapy to C&S report.

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).

Culture & Susceptibility (C&S) Investigation

  • 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.
  • Base empiric treatment on prior culture data. If stable vitals & afebrile, provide definitive therapy when new C&S result.


  • 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.


  1. Executive Summary: International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: CID 2011;52(5):561–564.
  2. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: CID 2010; 50:625–663.
  3. IDSA Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. CID 2005; 40:643–54.
  4. 2015 Updated Beers Criteria


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.

Last Updated 10-2018

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