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. Please refer to “Uncomplicated Cystitis” for choice of antibiotics.

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)

OR

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

OR

Cephalexin 500mg PO q12h

Duration: 5 days

Amoxicillin/clavulanate 625mg PO q8h

OR

Ampicillin/sulbactam 375-750mg PO q12h

OR

Cefuroxime 500mg PO q12h

Duration: 3-5 days

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.)

*Avoid Nitrofurantoin if GFR < 30ml/min.

Ciprofloxacin and other fluoroquinolones are highly efficacious in 3-day regimens but have a propensity for collateral damage and should be reserved for definitive therapy or severe infections. Fluoroquinolones can be considered alternative antimicrobials for patients who cannot tolerate the recommended antibiotics due to adverse effects such as drug allergy.

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%. If susceptible, trimethoprim-sulfamethoxazole 160/800 mg PO q12h for 3 days can be used for definitive therapy.

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 MDR pathogens sensitive to fosfomycin, to give every 48hrs for total 3 doses.

Outpatient treatment:

Amoxicillin/clavulanate 625mg PO q8h

OR

Ampicillin/sulbactam 375-750mg PO q12h

Duration: 7-10 days

Inpatient treatment:

Amoxicillin/clavulanate 1.2g IV q6h

OR

Ampicillin/sulbactam 1.5-3g IV q6h

Duration: 7 days 

Outpatient treatment:

*Ciprofloxacin 500mg q12h PO for 7 days 

Inpatient treatment:

Cefuroxime 750mg IV q8h

OR

Ceftriaxone 1g IV q24h 

Duration: 7 days

Perform ultrasound of the upper urinary tract to exclude obstructive pyelonephritis. If there is evidence of obstruction, please refer to “Complicated UTI” section.

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.

*Ciprofloxacin has a propensity for collateral damage and potential adverse effects.

*Amoxicillin/clavulanate 1.2g IV q6h 

OR

Ampicillin/sulbactam 1.5-3g IV q6h

MAY ADD

**Aminoglycoside

Cefuroxime 750mg-1500mg IV q8h

OR

Ceftriaxone 1-2g IV q24h

MAY ADD

**Aminoglycoside

Duration: 10-14 days

For mild or moderate CAUTIs, especially in stable patients with no signs of systemic infection, oral antibiotics may be sufficient, provided that the chosen antibiotic is effective against the identified pathogen. The choice between oral and IV antibiotics should be guided by clinical judgment, the patient's overall condition, and the results of urine culture and sensitivity testing.

**Consider adding aminoglycoside (E.g.: amikacin) in patients with severe pyelonephritis, or risk factors for pseudomonas aeruginosa or MDR organisms.

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.

*Amoxicillin/clavulanate is generally safe in pregnancy (category B) but may have an increased risk of necrotizing enterocolitis associated with its use in pre-term and premature rupture of membrane.

Pyuria alone in the absence of other symptoms is not diagnostic of CA-UTI. Remove unnecessary catheters. Whenever indicated, change catheter prior to starting treatment.

*Piperacillin-tazobactam 4.5g IV q6-8h

OR

Cefepime 2g IV q8h 

**Meropenem 1g IV q8h

OR

**Imipenem 500mg IV q8h 

*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 q6h

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:

Trimethoprim/Sulfamethoxazole 160/800mg PO q12h

OR

Ciprofloxacin 500mg PO q12h

Inpatient treatment:

Amoxicillin/clavulanate 1.2g IV q6h

OR

Ampicillin/sulbactam 3g IV q6h

MAY ADD

Gentamicin 5mg/kg IV q24h

Inpatient treatment:

Cefuroxime 750mg-1500mg IV q8h

OR

Ceftriaxone 1-2g IV q24h

MAY ADD

Gentamicin 5mg/kg IV q24h

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

Ciprofloxacin 500mg PO q12h for 4-6 weeks

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

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, please refer to Sexually Transmitted Infection section section for choice of antibiotics.

Amoxicillin/clavulanate 1.2g IV q6h

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

Surgical drainage is the mainstay of treatment.

*Piperacillin-tazobactam 4.5g IV q6-8h

Ceftriaxone 2g IV q24h

PLUS

Metronidazole 500mg IV q8h 

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).