Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

asymptomatic bacteriuria before urological procedure

1st line – oral antibiotic therapy

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INITIAL
|
asymptomatic bacteriuria before urological procedure
1st line – 

oral antibiotic therapy

The purpose of therapy is to temporarily eliminate bacteriuria, because the presence of non-sterile urine during urological procedures increases the risk of bacteraemia and sepsis.

The optimal choice of antibiotics and timing and duration of therapy have not been well defined by clinical trials. However, treatment should occur before urological procedures that may disrupt the mucosal lining of the urinary tract.[4] A urine culture with antibiotic sensitivities obtained several days before the procedure will help to guide antibiotic choices.

Fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[59] Warnings have also been issued about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[60][61] Depending on patient characteristics and local resistance patterns, fluoroquinolone antibiotics nevertheless remain a reasonable first-line choice for treatment of UTI in men due to the higher risk of a complicated course in this patient group.[44]

After the procedure, the antibiotic can be discontinued unless a catheter remains in place.

Risks relate to the specific adverse effects of the antibiotic chosen and general antibiotic complications, such as pseudomembranous colitis or induction of resistance.

Primary options

trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily for 1-2 days

OR

nitrofurantoin: 100 mg orally 4 times daily for 1-2 days

OR

amoxicillin/clavulanate: 500 mg orally 3 times daily for 1-2 days

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OR

cefalexin: 500 mg orally 4 times daily for 1-2 days

OR

levofloxacin: 500 mg orally once daily for 1-2 days

OR

ciprofloxacin: 500 mg orally twice daily for 1-2 days

ACUTE

not severe and tolerating oral therapy

1st line – oral antibiotic therapy

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ACUTE
|
not severe and tolerating oral therapy
1st line – 

oral antibiotic therapy

The choice of initial empirical therapy should be guided by local resistance patterns.[44] All men should have a urine culture to assure that the initial empirical antibiotic choice is appropriate.

Treatment options include beta-lactams, trimethoprim/sulfamethoxazole (TMP/SMX), nitrofurantoin, and fluoroquinolones.[10][44]

Risks relate to the specific adverse effects of the antibiotic chosen and general antibiotic complications such as pseudomembranous colitis or induction of resistance.

Fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[59] Warnings have also been issued about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[60][61] Depending on patient characteristics and local resistance patterns, fluoroquinolone antibiotics remain a reasonable first-line choice for treatment of UTI in men due to the higher risk of a complicated course in this patient group.[44] Due to high levels of resistance, the European Association of Urology recommends against the use of fluoroquinolones for the empirical treatment of complicated UTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months.[44] TMP/SMX may be used first-line in younger men without evidence of complicated UTI and with consideration to local resistance patterns.

Antibiotic dosing may need to be altered based on the patient's renal status.

Catheter-associated UTI (a complicated UTI) must be treated with diligence because of the risk of developing bacteraemia, but screening for or treatment of asymptomatic bacteriuria in catheterised patients is not recommended.[4][Evidence A][Evidence C] If therapy is initiated, then the catheter should be changed before starting antibiotics.[29][44]​​​​​

Treatment for 7 to 14 days is generally recommended.[44]

Primary options

trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily for 7-14 days

OR

nitrofurantoin: 100 mg orally 4 times daily for 7-14 days

OR

amoxicillin/clavulanate: 500 mg orally 3 times daily for 7-14 days; or 875 mg orally twice daily for 7-14 days

More

OR

cefalexin: 500 mg orally 4 times daily for 7-14 days

OR

levofloxacin: 750 mg orally once daily for 7-14 days

OR

ciprofloxacin: 500 mg orally twice daily for 7-14 days

severe or not tolerating oral therapy

1st line – hospitalisation plus intravenous antibiotic therapy

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ACUTE
|
severe or not tolerating oral therapy
1st line – 

hospitalisation plus intravenous antibiotic therapy

The choice of initial empirical therapy should be guided by local resistance patterns.[44] All men should have a urine culture to assure that the initial empirical antibiotic choice is appropriate.

Treatment options include beta-lactam antibiotics (often in combination with other antibiotics [e.g., aminoglycosides]), and fluoroquinolones.[10][44]

In the setting of increasing drug resistance in uropathogens, the following treatments are also approved in some countries for use in adults with complicated UTI caused by susceptible organisms who have limited or no alternative options: meropenem/vaborbactam, plazomicin, cefiderocol, and imipenem/cilastatin/relebactam.[64][65][66][67][68]

Intravenous antibiotics are continued until the patient is stabilised and can tolerate oral therapy.

Risks relate to the specific adverse effects of the antibiotic chosen and general antibiotic complications, such as pseudomembranous colitis or induction of resistance.

Fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[59] Warnings have also been issued about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[60][61] Depending on patient characteristics and local resistance patterns, fluoroquinolone antibiotics nevertheless remain a reasonable first-line choice for treatment of UTI in men due to the higher risk of a complicated course in this patient group.[44]

Due to high levels of resistance, the European Association of Urology recommends against the use of fluoroquinolones for the empirical treatment of complicated UTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months.[44]

Dosing may need to be altered based on the patient's renal status, and consideration should be given to the possibility of Pseudomonas infection in catheterised patients.

Catheter-associated UTI (a complicated UTI) must be treated with diligence because of the risk of developing bacteraemia, but screening for or treatment of asymptomatic bacteriuria in catheterised patients is not recommended.[4][Evidence A][Evidence C] If therapy is initiated, then the catheter should be changed before starting antibiotics.[29]​[44]​​​​​​

Treatment for 7-14 days is generally recommended.[44]

Primary options

ceftriaxone: 1-2 g intravenously every 24 hours

OR

ampicillin: 2 g intravenously every 6 hours

and

gentamicin: 1.5 mg/kg intravenously every 8 hours

OR

gentamicin: 1.5 mg/kg intravenously every 8 hours

OR

ticarcillin/clavulanic acid: 3.2 g intravenously every 8 hours

More

OR

imipenem/cilastatin: 500 mg intravenously every 6-8 hours

More

OR

aztreonam: 1 g intravenously every 8 hours

OR

piperacillin/tazobactam: 2.25 to 4.5 g intravenously every 6 hours

More

OR

meropenem/vaborbactam: 4 g intravenously every 8 hours

More

OR

plazomicin: 15 mg/kg intravenously every 24 hours, maximum 7 days treatment

OR

cefiderocol: 2 g intravenously every 8 hours

OR

imipenem/cilastatin/relebactam: 1.25 g intravenously every 6 hours

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OR

levofloxacin: 750 mg intravenously every 24 hours

OR

ciprofloxacin: 400 mg intravenously every 12 hours

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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