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Empiric antimicrobial agent selection for acute complicated urinary

tract infection

Patient Risk for MDR?

Empiric regimens Comments
population *

Hospitalized with: N/A Vancomycin 15 to 20 The rationale for

Critical mg/kg IV every 8 to 12 broad coverage is
illness hours with or without a the high risk of
warranting loading dose adverse outcomes
intensive plus with insufficient
care (eg, An antipseudomonal antimicrobial
severe carbapenem: therapy.
sepsis) or Imipenem 500 mg IV Regimens with a
Urinary every 6 hours or narrower
tract Meropenem 1 g IV spectrum (eg,
obstruction every 8 hours or regimens listed
for other
Doripenem 500 mg IV
hospitalized
every 8 hours
patients without
MDR risk) may be
appropriate in
regions with low
community
prevalence of
MDR organisms.

Other No Ceftriaxone 1 g IV once If Enterococcus or

hospitalized daily or Staphylococcus
patients Piperacillin-tazobactam species are
3.375 g IV every 6 hours or suspected (based
Alternatives: on prior isolates
or gram-positive
Levofloxacin 750 mg IV
cocci on urine
or orally daily
Gram stain),
Ciprofloxacin 400 mg IV
piperacillin-
twice daily
tazobactam is
Ciprofloxacin 500 mg
 orally twice daily preferred.
Ciprofloxacin extended- If Pseudomonas is
release 1000 mg orally suspected (based
once daily on prior isolates),
piperacillin-
tazobactam or a
fluoroquinolone is
preferred.

Yes Piperacillin-tazobactam If VRE or MRSA are

3.375 g IV every 6 hours or suspected (based
An antipseudomonal on prior isolates
carbapenem: or gram-positive
Imipenem 500 mg IV cocci on urine
every 6 hours or Gram stain),
vancomycin (for
Meropenem 1 g IV
MRSA) or
every 8 hours or
daptomycin or
Doripenem 500 mg IV
linezolid (for VRE)
every 8 hours
is added.

Outpatients No, and no For patients with low risk If the community
concerns with of fluoroquinolone prevalence of
fluoroquinolones resistance/toxicity: fluoroquinolone
(eg, at low risk Ciprofloxacin 500 mg resistance in
for adverse orally twice daily for 5 Escherichia coli is
effects) to 7 days or known to be
Ciprofloxacin extended- >10%, give one
release 1000 mg orally dose of a long-
once daily for 5 to 7 acting parenteral
days or agent prior to the
fluoroquinolone:
Levofloxacin 750 mg
orally once daily for 5 Ceftriaxone 1
to 7 days g IV or IM
once
Ertapenem 1 g
IV or IM once
Gentamicin 5
mg/kg IV or IM
once
Tobramycin 5
mg/kg IV or IM
once

No, but with For patients who cannot In outpatients

concerns with use a fluoroquinolone: who are
fluoroquinolones One dose of a long- systemically ill or
(eg, at risk for acting parenteral are at risk for
adverse effects) agent: more severe
Ceftriaxone 1 g IV illness, we favor
or IM once or continuing the
Ertapenem 1 g IV or parenteral agent
IM once or until culture and
susceptibility
Gentamicin 5
testing results can
mg/kg IV or IM
guide selection of
once or
an appropriate
Tobramycin 5
oral agent.
mg/kg IV or IM
once
Followed by one of the
following:
TMP-SMX one
double-strength
tablet orally twice
daily for 7 to 10
days or
Amoxicillin-
clavulanate 875 mg
orally twice daily for
10 to 14 days or
Cefpodoxime 200
mg orally twice
daily for 10 to 14
days or
Cefdinir 300 mg
orally twice daily for
10 to 14 days or
Cefadroxil 1 g orally
twice daily for 10 to
14 days

Yes Ertapenem 1g IV or IM If the patient

once cannot take a
Followed by: fluoroquinolone
Ciprofloxacin 500 mg or has high risk
orally twice daily for 5 for
to 7 days or fluoroquinolone
resistance
Ciprofloxacin extended-
(fluoroquinolone-
release 1000 mg orally
resistant isolate or
once daily for 5 to 7
fluoroquinolone
 days or use in prior three
Levofloxacin 750 mg months):
orally daily for 5 to 7 Ertapenem 1 g
days IV or IM once
daily until
cultures and
susceptibility
testing return

These antibiotic regimens represent our approach to empiric treatment for acute complicated
UTI. Once culture and susceptibility testing results are available, the regimen should be
tailored to those results. If feasible, an antibiotic with a narrow spectrum of activity should be
chosen to complete the antibiotic course.

MDR: multidrug resistance; ​ IV: intravenous; ​ VRE: vancomycin-resistant Enterococcus; ​ MRSA:

methicillin-resistant Staphylococcus aureus; ​ IM: intramuscular; ​ TMP-SMX: trimethoprim-
sulfamethoxazole;​ UTI: urinary tract infection.

​ * Risk factors for MDR gram-negative UTIs include any one of the following in the prior three
months:​
An MDR, gram-negative urinary isolate
Inpatient stay at a health care facility (eg, hospital, nursing home, long-term acute care
facility)
Use of a fluoroquinolone, TMP-SMX, or broad-spectrum beta-lactam (eg, third- or later-
generation cephalosporin)
Travel to parts of the world with high rates of MDR organisms

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