Treatment is NOT indicated unless:

• *In pregnant women

• **Prior to transurethral resection of prostate (TURP) or urological procedures breaching the mucosa 

--

*Duration of treatment for pregnant women: 5 days.

**Duration of treatment for preemptive treatment of ABU before TURP or urological procedures breaching the mucosa: 3-5 days. Follow up urine culture is not necessary prior to the procedure. 

Do not screen or treat asymptomatic bacteriuria in the following conditions:

• Women without risk factors

• Post-menopausal women

• Patients with indwelling or suprapubic catheters and nephrostomy tubes

• Elderly institutionalized patients

• Patients with dysfunctional and/or reconstructed lower urinary tracts

• Patients with renal transplants

• Patients prior to arthroplasty surgeries

• Patients with history of recurrent urinary tract infections

*Nitrofurantoin 50-100mg PO q6h (macrocrystals, immediate-release)

OR

Nitrofurantoin 100mg PO q12h (monohydrate/macrocrystals, sustained-release)

OR

Amoxicillin/clavulanate 625mg PO q8h

OR

Ampicillin/sulbactam 375-750mg PO q12h

Cephalexin 500mg PO q12h

OR

Cefuroxime 250-500mg PO q12h

OR

**Fosfomycin 3g PO x 1 dose

(Unlikely to be effective for gram negative other than E. coli. Other gram-negative infection carry FosA hydrolase gene that may deactivate fosfomycin and leads to clinical failure)

Duration: 3-5 days. The treatment duration is counted starting from the first day of effective antibiotic therapy.

*Avoid Nitrofurantoin if GFR < 30ml/min and pregnant women at third trimester.

Trimethoprim-sulfamethoxazole is not recommended to be used as empirical therapy for UTI as the local resistance rates of E. coli and Klebsiella pneumoniae has been consistently > 30%. 

Amoxicillin or ampicillin should not be used for empirical treatment given the relatively poor efficacy and the very high prevalence of antimicrobial resistance.

**If confirmed ESBL E.coli sensitive to fosfomycin, to give every 48hrs for total 3 doses.

Amoxicillin/clavulanate 1.2g IV q6-8h 

OR

Ampicillin/sulbactam 1.5-3g IV q6h

MAY ADD

*Aminoglycoside

Cefuroxime 750mg-1500mg IV q8h

OR

Ceftriaxone 2g IV q24h

OR

*Ceftazidime 2g IV q8h

Duration: 5-7 days

*Consider using ceftazidime or adding aminoglycoside (E.g.: amikacin) in patients at risk of Pseudomonas aeruginosa infection.

Consider stepping down to oral antibiotics based on culture and sensitivity result once patient is afebrile for > 48 hours, clinically improving and able to take oral medications.

Pyuria alone in the absence of other symptoms is not diagnostic of CA-UTI and treatment is not indicated.

Urosepsis WITHOUT shock:

Ceftriaxone 2g IV q24h

OR

Cefotaxime 2g IV q8h

Urosepsis WITH shock:

*Piperacillin-tazobactam 4.5g IV q6-8h

Urosepsis WITHOUT shock:

Ceftazidime 2g IV q8h

OR

Cefepime 2g IV q8h

Urosepsis WITH shock:

**Meropenem 1g IV q8h

OR

**Imipenem 500mg IV q6h 

Duration: 7 days or more

For patients with abscesses in the urinary tract or bacterial prostatitis, please refer to respective sections for the duration and choice of antibiotics. 

*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours). 

**Carbapenem should be reserved for urosepsis with risk factors for MDR or ESBL-producing organism.

Nitrofurantoin 50-100mg PO ON (macrocrystals)

OR

Nitrofurantoin 100mg PO ON (monohydrate/macrocrystals, dual release)

OR

Cephalexin 250mg PO ON

Trimethoprim/sulfamethoxazole 80/400mg PO ON

OR

Trimethoprim 100mg PO ON

Antimicrobial prophylaxis is indicated if non-antimicrobial measures (behavioral and personal hygiene) fail.

Continuous prophylaxis for 3-12 months or intermittent post-coital prophylaxis (a single dose of antibiotics taken within the 2-hour period after sexual intercourse).

Long-term use of nitrofurantoin has been associated with an increased risk of rare adverse effects, including pulmonary toxicity, hepatotoxicity and peripheral polyneuropathy.

Aerobic infection:

Mupirocin ointment 2% LA q12h to q8h for 7-10 days

MAY ADD

Amoxicillin/clavulanate 625 mg PO q8h for 7 days (for severe cases)

Anaerobic infection: 

Amoxicillin/clavulanate 625 mg PO q8h for 7 days

--

--

Clotrimazole cream 1% q12h for 7-14 days

OR 

Miconazole cream 2% q12h 7-14 days

For severe cases,

MAY ADD

Fluconazole 200 mg PO q24h

MAY ADD

Hydrocortisone cream 1% q12h (if marked inflammation is present)

--

--

Amoxicillin/clavulanate 1.2g IV q6-8h

OR

Ampicillin/sulbactam 3g IV q6h

MAY ADD

Gentamicin 5mg/kg IV q24h

Cefuroxime 750mg-1500mg IV q8h

OR

Ceftriaxone 2g IV q24h

MAY ADD

Gentamicin 5mg/kg IV q24h

Source control by surgical or pigtail drainage is the mainstay of treatment.

Duration of antibiotics: 2-3 weeks (of both IV and oral). The duration of antibiotics should be determined by the extent of infection, source control, clinical response, resolution on follow-up imaging, and normalization of inflammatory markers.

Consider stepping down to oral antibiotics based on culture and sensitivity results once the patient is afebrile for >48 hours, clinically improving and able to take oral medications.

Outpatient treatment:

Ciprofloxacin 500-750mg PO q12h

Inpatient treatment:

*Ciprofloxacin 400mg IV q12h

OR

Amoxicillin/clavulanate 1.2g IV q6h

OR

Ampicillin/sulbactam 3g IV q6h

MAY ADD

**Aminoglycoside

Outpatient treatment:

Trimethoprim/Sulfamethoxazole 160/800mg PO q12h

Inpatient treatment:

Cefuroxime 750mg-1500mg IV q8h

OR

Ceftriaxone 2g IV q24h

OR

**Ceftazidime 2g IV q8h

Obtain urine culture before starting treatment.

Duration of antibiotics: Minimum 10-14 days or up to 6 weeks depending on the severity and clinical response.

Consider stepping down to oral antibiotics based on culture and sensitivity results once the patient is afebrile for >48 hours, clinically improving and able to take oral medications.

If the patient has risk factors for sexually transmitted disease, please refer to Sexually Transmitted Infection section for choice of antibiotics.

*PO ciprofloxacin may be considered for patients who are not septic and can tolerate orally, as it has similar bioavailability to the IV formulation.

**Consider using ceftazidime or adding aminoglycoside (E.g.: amikacin) in patients at risk of Pseudomonas aeruginosa infection.

Ciprofloxacin 500-750mg PO q12h for 4-6 weeks

Trimethoprim/ Sulfamethoxazole 160/800mg PO q12h for 4-12 weeks 

OR

*Doxycycline 100mg PO q24h for 10 days 

OR 

**Azithromycin 500mg PO q24h for 3 weeks

Referral to urologist is recommended to differentiate from chronic non-bacterial prostatitis before starting antibiotics.

Ciprofloxacin, despite the high resistance rates of uropathogens, is recommended as first line agent in the empirical treatment of chronic bacterial prostatitis due to the favorable pharmacokinetic properties.

*Doxycycline - Only for C. trachomatis or mycoplasma infections

**Azithromycin - Only for Trichomonas vaginalis infections

Levofloxacin 500mg PO q24h for 10 days

Ciprofloxacin 500mg PO q12h for 10-14 days

OR

Trimethoprim/ Sulfamethoxazole 160/800mg PO q12h for 10 days

OR 

Ofloxacin 200mg PO q12h for 14 days

If patient has risk factors for sexually transmitted disease or sexually active, please refer to Sexually Transmitted Infection section for choice of antibiotics.

Amoxicillin/clavulanate 1.2g IV q6-8h

OR

Ampicillin/sulbactam 3g IV q6h

Cefuroxime 750mg-1500mg IV q8h

OR

Ceftriaxone 2g IV q24h

OR

*Ciprofloxacin 400mg IV q12h

Surgical drainage is the mainstay of treatment.

*Ciprofloxacin 500-750mg PO q12h may be considered as outpatient treatment for small testicular abscesses that are not suitable for drainage.

*Piperacillin-tazobactam 4.5g IV q6-8h

Ceftriaxone 2g IV q24h

PLUS

Metronidazole 500mg IV q8h

OR 

**Meropenem 1g IV q8h

OR 

**Imipenem 500mg IV q6h

Aggressive surgical debridement is the mainstay of treatment.

Antibiotics are given until source control is achieved. 

*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours). 

**Carbapenem should be reserved for Fournier’s Gangrene with risk factors for MDR or ESBL-producing organisms.