Urinary Tract Infection
Page updated Winter 2021.
Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable sources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original sources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.
Acute Uncomplicated Cystitis
Nitrofurantoin
Monohydrate/ macrocrystals (Macrobid)
100 mg twice daily for 5 days
It is an appropriate choice.
Its efficacy is comparable to 3 days of trimethoprim-sulfamethoxazole.
There is minimal resistance and propensity for collateral damage.
Trimethoprim-sulfamethoxazole
160/800 mg twice-daily for 3 days.
It is an appropriate choice.
Fluoroquinolones
3-day regimens
Options: ofloxacin, ciprofloxacin, and levofloxacin
Highly efficacious
Should be considered an alternative antimicrobials for acute cystitis, when other options don't work.
Fosfomycin
3 g in a single dose; It has inferior efficacy.
B-Lactam agents
3–7-days; Choices are:
amoxicillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil
Inferior efficacy
More adverse effects
Should be used with caution for uncomplicated cystitis.
Emphysematous Cystitis
Antibiotics
Broad gram-negative coverage- IV
Enterococcal coverage if Gram stain shows gram-positive cocci
Bladder drainage
Treatment of comorbid conditions : treating diabetes
Surgery
Rarely needed. Case reports have described debridement, partial cystectomy, and total cystectomy.
Asymptomatic Bacteriuria
Do not screen or treat
Pediatric patients
Women without risk factors
Post-menopausal women
Patients with well-regulated diabetes mellitus
Elderly institutionalised patients
Patients with dysfunctional and/or reconstructed lower urinary tracts
Patients with renal transplants
Prior to arthoplasty surgeries
Patients with recurrent urinary tract infections
Pyuria accompanying asymptomatic bacteriuria
Should not be treated with antimicrobial therapy.
Screen and treat
Prior to urological procedures breaching the mucosa
Pregnant women
Renal transplant patients
If >1 month after renal transplant: no treatment.
Nonrenal solid organ transplant
No treatment.
High-risk neutropenia
Absolute neutrophil count <100 cells/mm3, ≥7 days duration following chemotherapy
No recommendation for or against treatment
Asymptomatic Bacteriuria and Cystitis in Pregnancy
Cephalexin: 500 mg four times daily
Nitrofurantoin
No G6PD deficiency
Not in 38 to 42 weeks' gestation
Acute Pyelonephritis
Not requiring hospitalization
Oral ciprofloxacin
500 mg twice daily for 7 days
Intravenous ciprofloxacin
400-mg, one initial dose
May or may not be given.
Requiring hospitalization
Intravenous Antibiotics for 10-14 days. Choices are:
Fluoroquinolone- Not a good choice for complicated PN.
Extended-spectrum cephalosporin
Extended-spectrum penicillin
Carbapenem
In case of gram-positive cocci in initial Gram stain enterococcal coverage should be included.
Urosepsis
Diagnosis
Urine culture
Two sets of blood culture
Other related tests to rule out other sources of sepsis
Treatment
Resuscitation
Antibiotics- IV broad spectrum antimicrobials. Refer to common medication page.
Removal of foreign bodies
Decompression of obstruction
Drainage of abscesses
Acute Pyelonephritis in Pregnancy
Hospitalize
IV fluids
Cooling blanket
Acetaminophen
IV antibiotics:
Second or third generation cephalosporins
Carbapenems: in severe multidrug-resistant infection.
Renal ultrasound: if no improvement in 72 hours
Asymptomatic Candiduria
Elimination of predisposing factors
Indwelling bladder catheters
Systemic antifungal treatment
Treatment with antifungal agents is NOT recommended.
Treat only if:
Neutropenic- Candidemia Protocol
Very low-birth-weight infants (<1500 g)- Candidemia Protocol
Before urologic manipulation- Fluconazole
For doses refer to common medication page.
Symptomatic Candida Cystitis
Antifungal treatment
Refer to common medication page.
Amphotericin B deoxycholate irrigation
50 mg/L sterile water daily for 5 days.
Irrigation may be helpful for treatment of cystitis due to fluconazole-resistant species, such as C. glabrata and C. krusei.
Symptomatic Ascending Candida Pyelonephritis
Antifungal treatment
Refer to common medication page.
Elimination of urinary tract obstruction
Nephrostomy tubes or stents removal or replacement
Fungus Balls
Surgical intervention
Antifungal treatment
Amphotericin B deoxycholate Irrigation
Use nephrostomy tubes, if present.
25–50 mg in 200–500 mL sterile water
Infected Hydronephrosis and Pyonephrosis
Antimicrobial therapy
Drainage
Ureteral catheter or percutaneous nephrostomy tube
Emphysematous pyelonephritis
Fluid resuscitation
Glucose management
Electrolyte management
Antimicrobial therapy
Drainage:
Ureteral catheter or percutaneous nephrostomy tube
Nephrectomy:
Only if there is extensive diffuse gas with renal destruction.
Renal Abscess
<3 - 5 cm
Antibiotics alone
Drainage if not responsive to initial antibiotic therapy.
Drainage if immunocompromised.
> 5 cm
Antibiotics
Percutaneous drainage
They usually require multiple drains, and multiple drain manipulations.
Surgical washout and potential nephrectomy might be needed.
Perinephric Abscess
<3 cm
Antibiotics:
There should be gram negative and staphylococcal coverage.
Percutaneous drainage
If not responsive to initial antibiotic therapy.
> 3 cm
Antibiotics
Percutaneous drainage
Addressing the underlying problem
Xanthogranulomatous Pyelonephritis
Antibiotics
Nephrectomy:
It is usually performed.
Partial nephrectomy:
If localized.
Malacoplakia
Antibiotics
Recurrent infection should be controlled.
Tuberculosis
Most common presentations:
Hematuria (gross or microscopic), sterile pyuria, storage symptoms, dysuria, fever, and weakness.
Other presentations:
Pyospermia and hematospermia may occur in men with prostate tuberculosis in endemic areas. If there is history of tuberculosis, investigate for urogenital tuberculosis.
Tuberculous epididymitis may occur, typically as chronic epididymitis, in high-risk groups such as men with immunodeficiency and those from endemic areas. It frequently results in a discharging scrotal sinus.
Diagnosis
Three sequential early morning urine samples:
Cultured for acid-fast bacilli (AFB)
and
NAAT for M. tuberculosis
AFB culture and NAAT test of other secretions
Prostate secretion
Ejaculate
Draining scrotal fistula
Fine needle aspiration and biopsy