GUIDELINES ON

UTI
• SOURCE:
The Philippine Clinical Practice Guidelines on the
Diagnosis and Management of Urinary Tract
Infections in Adults.

Update 2004
 ACUTE UNCOMPLICATED CYSTITIS
• Suspected in:
– Non-pregnant women
– Presenting with:
• Dysuria
• Frequency
• Gross hematuria with or without pain
– No risk factors for complicated UTI
 ACUTE UNCOMPLICATED CYSTITIS
• Risk Factors for complicated UTI
– Hospital acquired infection
– Indwelling urinary catheter
– Recent urinary tract infection
– Recent urinary tract instrumentation (in the past 2 weeks)
– Functional or anatomic abnormality of the urinary tract
– Recent antimicrobial use (in the past 2 weeks)
– Symptoms for >7 days at present
– Diabetes mellitus
– Immunosuppression
 ACUTE UNCOMPLICATED CYSTITIS
• Diagnostics
– Pre-treatment urine culture is NOT recommended (Grade
E)
– Standard urine microscopy and dipstick leukocyte esterase
(LE) and nitrite tests are NOT prerequisites for treatment
(Grade D)
– In women with additional symptoms such as vaginal
discharge or irritation, a standard urine microscopy or
dipstick for LE and nitrites can be done to confirm the
diagnosis (Grade B)
 ACUTE UNCOMPLICATED CYSTITIS
• Treatment
Antibiotics Dose and Frequency Duration
TMP-SMX 800/160mg BID 3days
Ciprofloxacin 250mg BID 3 days
Ofloxacin 200mg BID 3 days
Norfloxacin 400mg BID 3 days
Levofloxacin 250mg OD 3 days
Gatifloxacin 400mg Single dose
Nitrofurantoin 100mg QID 7 days
Cefixime 400 mg OD 3 days
Cefuroxime 125-250mg BID 3-7 days
Co-amoxiclav 625mg BID 7days
ACUTE UNCOMPLICATED CYSTITIS
• Any of the antibiotics listed can be used depending
on local susceptibility patterns and host factors
• Recommended antibiotics may change depending on
the local patterns of susceptibility.
• Ampicillin and amoxicillin should NOT be used.
• Exercise caution when prescribing fluoroquinolones
to elderly.
– Fluoroquinolone-related disturbances in blood glucose
control more common in elderly patients (Sprandel, 2003)
 ACUTE UNCOMPLICATED CYSTITIS
• Effective duration of treatment
– 3-day therapy is recommended (Grade A)
– Except for Nitrofurantoin, which must be given for 7 days
(Grade A)
 ACUTE UNCOMPLICATED CYSTITIS
• If symptoms worsen, do not completely resolve or do
not improve after completion of a 3-day therapy
– Urine culture should be collected
– Change antibiotics empirically, pending results of
sensitivity testing (Grade C)
– If symptoms failed to resolve after the 7-day treatment,
managed as a complicated UTI (Grade C)
 ACUTE UNCOMPLICATED CYSTITIS
• Post treatment diagnostics
– Routine post-treatment urine culture and urinalysis in
patients whose symptoms have completely resolved are
NOT recommended (Grade D)
 ACUTE PYELONEPHRITIS
• Clinical presentation:
– Fever( T>/= 38C)
– Chills
– Flank pain
– Costovertebral angle tenderness
– Nausea and vomiting
– With or without signs and symptoms of lower UTI
• Laboratory findings:
– Pyuria (>/= 5wbc/hpf) on urinalysis
– Bacteruria (>/=10,000 cfu/ml) on urine culture
 ACUTE PYELONEPHRITIS
• Diagnostics
– Urinalysis and Gram stain are recommended (Grade B).
– Urine culture and sensitivity test should also be performed
routinely to facilitate cost effective use of antibiotics
(Grade B).
– Blood cultures are NOT routinely recommended (Grade D).
 ACUTE PYELONEPHRITIS
• Treatment and Management
– Treat as OUT PATIENT:
• Non pregnant patients with no signs and symptoms of
sepsis
• likely to adhere to treatment and return for follow-up
– Initial IV dose of Ceftriaxone may be given followed by an
oral antibiotic (Grade B).
 ACUTE PYELONEPHRITIS
• Indications for admission (Grade B):
– Inability to maintain oral hydration or take medications
– Concern about compliance
– Presence of possible complicating conditions
– Severe illness with high fever
– Severe pain
– Marked debility and signs of sepsis
 ACUTE PYELONEPHRITIS
• Antibiotics for Empiric Treatment
– Fluoroquinolones, aminolycosides, 3rd and 2nd generation
caphalosporins, extended penicillins are recommended
(Grade A).
– Ampicillin, amoxicillin and 1st generation cephalosporins
are NOT recommended (Grade E).
– TMP-SMX is NOT recommended due to high resistance
rates, but can be used when the organism is susceptible.
 ACUTE PYELONEPHRITIS
– Combining ampicillin with an aminoglycoside offers no
added benefit, except when enterococcal infection is
suspected (Grade C).
– IV antibiotics can be shifted to oral once patient is afebrile
(Grade B).
– Choice of antibiotic therapy should be guided by urine
culture and sensitivity results (Grade B).
 ACUTE PYELONEPHRITIS
• Oral antibiotics
Antibiotic and Dose Frequency and Duration
Ofloxacin 400 mg BID; 14 days
Ciprofloxacin 500 mg BID; 7-10 days
Gatifloxacin 400 mg OD; 7-10 days
Levofloxacin 250 mg OD; 7-10 days
Cefixime 400 mg BID; 14 days
Co-amoxiclav 625mg (if with gram + TID; 14 days
organism)
 ACUTE PYELONEPHRITIS
• Parenteral antibiotics (given until patient is afebrile)
Antibiotic and Dose Frequency and Duration
Ceftriaxone 1-2g Q24h
Ciprofloxacin 200-400 mg Q12h
Levofloxacin 250-500 mg Q24h
Gatifloxacin 400 mg Q24h
Gentamicin 3-5mg/kg BW (+/- Q24h
ampicillin)
Ampicillin-sulbactam 1.5 g (if with gram Q6h
+ organism)
Pip-Tazo 2.25-4.5g Q6-8h
 ACUTE PYELONEPHRITIS
• Duration of treatment
– 14 days is recommended.
– Selected fluoroquinolones can be given 7-10 days (Grade
A)
 ACUTE PYELONEPHRITIS
• Work-up for urologic abnormalities
– Routine urologic evaluation and routine use of imaging
procedures are NOT recommended (Grade D).
– Consider radiologic evaluation if patient remains febrile
within 72 hrs of treatment or if with recurrent symptoms
(Grade C).
 ACUTE PYELONEPHRITIS
• Follow-up urine culture
– NOT necessary in patients clinically responding to therapy
< 72 hrs after initiation of treatment (Grade C).
– NOT recommended in patients who are clinically improved
(Grade C).
– Repeat if symptoms
• do not improve during therapy
• recur after treatment (Grade C)
 ACUTE PYELONEPHRITIS
• Management for recurrence of symptoms
– Antibiotic treatment based on urine culture and sensitivity
test results
– Assess for underlying genitourologic abnormality (Grade C)
– 2-week duration of re-treatment, if without urologic
abnormality
– 4-6 week regimen for patients whose symptoms recur and
whose culture shows the same organism as the initial
infecting organism
 ASYMPTOMATIC BACTERIURIA
• Clinical presentation:
– No symptoms attributable to UTI
• Labs:
– >/= 100,000 cfu/ml in 2 consecutive midstream urine
specimens or in 1 catheterized urine specimen
 ASYMPTOMATIC BACTERIURIA
• Who should NOT be screened and treated for ASB?
– Healthy adults (Grade D)
– Diabetics with adeqaute glycemic control, no autonomic
neuropathy or azotemia (Grade E)
– Elderly patients(Grade E)
– Patients with indwelling catheters (Grade E)
– Immunocompromised patients (Grade C)
– Other solid oragan transplant patients (Grade C)
– HIV patients (Grade C)
– Spinal cord injury patients (grade D)
– Patients with urological abnormalities (Grade C)
 ASYMPTOMATIC BACTERIURIA
• Who should be screen and treated for ASB?
– Those who will undergo genitourinary manipulation or
instrumentation (Grade B).
– Post-renal transplant patients up to 6 months (Grade B).
– Patients with diabetes mellitus with poor glycemic control,
autonomic neuropathy or azotemia (Grade C).
– All pregnant women (Grade A).
 ASYMPTOMATIC BACTERIURIA
• Screening test
– Urine culture (Grade A)
– Significant pyuria (>10 wbc/hpf) or positive gram stain of
unspun urine (>/=2 micoorganism/oif) in 2 consecutive
midstream samples (Grade C).
– Urine culture is NOT necessary when
• (-) pyuria in UA
• (-) organisms in gram stain (Grade B).
 ASYMPTOMATIC BACTERIURIA
• Treatment
– 7-14 day course is recommended.
Antibiotics Dose and Antibiotics Dose and
Frequency Frequency
TMP-SMX 800/160mg BID Gatifloxacin 400mg
Ciprofloxacin 250mg BID Nitrofurantoin 100mg QID
Ofloxacin 200mg BID Cefixime 400 mg OD
Norfloxacin 400mg BID Cefuroxime 125-250mg BID
Levofloxacin 250mg OD Co-amoxiclav 625mg BID
 UTI IN PREGNANCY
• ASYMPTOMATIC BACTERIURIA IN PREGNANCY
– Clinical presentation:
• No symptoms of UTI
– Labs:
• Presence of >/= 100,000 cfu/ml of 1 or more
uropathogens in 2 consecutive midstream specimens
OR 1 catheterized specimen.
• 1 urine culture is an acceptable alternative.
– All pregnant women must be screened on 1st prenatal visit
between 9th to 17th week, preferably on the 16th week AOG
(Grade A).
 UTI IN PREGNANCY
• Diagnostics
– Standard urine culture of clean catch midstream urine is
the test of choice (Grade A).
– Urine dipstick for leukocyte and/or nitrite test are NOT
recommended for screening (Grade E).
– Urinalysis alone is NOT recommended (Grade E).
 UTI IN PREGNANCY
• Treatment
– Treatment is indicated
• to reduce the risk of acute cystitis and pyelonephritis,
LBW neonates and preterm infants (Grade A)
– Nitrofurantoin (not for near-term), co-amoxicalv,
cephalexin, and co-trimoxazole (not in 1st and 3rd
trimesters) (Grade B).
– 7-day course is recommended (Grade B).
– Follow up culture after completing treatment (Grade C).
 UTI IN PREGNANCY
• FDA Pregnancy risk and Hale’s lactation risk
categories for commonly prescribed antimicrobials in
UTI.
Category B, L1, L2 Category C, L3 Category D, L3
Nitrofurantoin TMP-SMX (avoid in 1st Aminoglycosides
Amoxiclav and 3rd trimester)
Cephalosporins
 UTI IN PREGNANCY
• ACUTE CYSTITIS IN PREGNANCY
– Clinical presentation:
• Urinary frequency
• Urgency
• Dysuria
• Bacteriuria without fever and costovertebral angle
tenderness
• Gross hematuria may be present
 UTI IN PREGNENCY
• Diagnostics
– Urine culture and sensitivity test
– Presence of significant pyuria defined as >/= 5 pus
cells/mm3 of uncentrifuged urine OR
– >/= 5 pus cells/hpf of centrifuged urine AND positive
leukocyte esterase and nitrite test (Grade C).
 UTI IN PREGNANCY
• Treatment
– Antibiotics to which E. coli is most sensitive and which are
safe to give during pregnancy should be used (Grade A)
– 7-day course is recommended (Grade C)
– If without urine culture and sensitivity, empiric therapy
should be based on local susceptibility patterns (Grade C).
 UTI IN PREGNANCY
• If results of a urine culture shows an organism
resistant to the empirically started antibiotic in a
clinically improving patient, should the antibiotic be
changed?
– Adjust antibiotic based on urine culture results (Grade C).
– Alternatively, repeat the urine culture.
• If sterile, continue with the same antibiotic.
• If bacteriuria persists, switch regimen based on culture
results (Grade C).
 UTI IN PREGNANCY
• Post-treatment urine culture
– Obtain to confirm eradication of bacteriuria and resolution
of infection.
– Pregnant patients with pyelonephritis, recurrent UTIs,
concurrent gestational DM, concurrent nephrolithiasis or
urolithiasis, and preeclamsia, should be monitored at
monthly intervals until delivery (Grade C).
 UTI IN PREGNANCY
• ACUTE PYELONEPHRITIS IN PREGNANCY
– Clinical presentation:
• Shaking chills
• Fever (T>38C)
• Flank pain
• Nausea and vomiting
• With or without signs and symptoms of lower UTI and
physical finding of costovertebral angle tenderness.
– Labs:
• pyuria of >/= 5 wbc/hpf of centrifuged urine and
bacteriuria of >/= 10,000 cfu/ml.
 UTI IN PREGNANCY
• Diagnostics:
– Gram stain of uncentrifuged urine is recommended,
• can guide choice of empiric antibiotic therapy (Grade
B).
– Urine culture and sensitivity test should also be performed
routinely (Grade B).
– Blood culture are NOT routinely recommended for all
pregnant patients with acute pyelonephritis (Grade D).
 UTI IN PREGNANCY
• Treatment
– All should be hospitalized and immediate antibiotics given
(Grade B).
– Treatment duration 10-14 days (Grade B).
– Any antibiotics for acute uncomplicated pyelonephritis can
be used EXCEPT for fluoroquinolones and aminoglycosides
(Grade B).
 UTI IN PREGNANCY
• Oral antibiotics
Antibiotic and Dose Frequency and Duration
Cefixime 400 mg BID; 14 days
Co-amoxiclav 625mg (if with gram + TID; 14 days
organism)

• Parenteral antibiotics
Antibiotic and Dose Frequency and Duration
Ceftriaxone 1-2g Q24h
Ampicillin-sulbactam 1.5 g (if with gram Q6h
+ organism)
Pip-Tazo 2.25-4.5g Q6-8h
 UTI IN PREGNANCY
– In the absence of urine culture, base empiric antibiotic on
local susceptibility patterns (Grade C).
– Consider OUTPATIENT therapy
• no signs and symptoms of sepsis
• able to take medications by mouth (Grade B).
 UTI IN PREGNANCY
• Post-treatment urine culture
– Obtain to confirm resolution of infection.
– Patients should be monitored at intervals until delivery
(Grade C).
 RECURRENT UTI
• Non pregnant woman
• No known urinary tract abnormalities
• Episodes of acute uncomplicated cystitis
documented by urine culture occurring more than 2x
a year.
 RECURRENT UTI
• Indication for prophylaxis
– Frequency of recurrence is not acceptable to the patient in
terms of level of discomfort or interference with activities
of daily living (Grade C).
 RECURRENT UTI
• Prophylactic regimens
A. Antibiotic prophylaxis
• Continuous prophylaxis, daily intake of low dose
antibiotic for 6-12 months (grade A), OR
• Post coital prophylaxis, intake of a single dose of
antibiotic immediately after sexual intercourse (Grade
A).
 RECURRENT UTI
• Prophylaxis
Antibiotics Recommended dose for Recommended dose for
continued prophylaxis post-coital prophylaxis
Nitrofurantoin 100mg at bedtime ------
Trimethoprim 100 mg at bedtime ------
TMP/SMX 40 mg/200mg at bedtime 40mg/200mg
Ciprofloxacin 125mg at bedtime 125 mg
Norfloxacin 200 ng at bedtime 200 mg
Ofloxacin ------- 100 mg
Pefloxacin 400 mg weekly
Ceflexin 125 mg at bedtime -------
Cefaclor 250 mg at bedtime -------
 RECURRENT UTI
B. Hormonal treatments in post-menopausal women
• Application of intravaginal estriol cream once a night for
2 weeks followed by twice-weekly applications for 8
months is recommended (Grade A).
• Low dose oral estrogen is NOT recommended for the
prevention of recurrent UTI (Grade D).
 RECURRENT UTI
C. Vaccines
• Insufficient evidence to recommend immuno-active E.
coli fractions (Uro-Vaxom) for the prevention of recurrent
UTI (Grade C).
 RECURRENT UTI
• How should individual episodes of UTI be treated in
women with recurrent UTI?
– Any of the antibiotics for acute uncomplicated cystitis may
be used.
– Intermittent self-administered therapy
• instructed to take 2 double strength tablets of
TMP/SMX single dose as soon as symptoms appear
(Grade A).
– Breakthrough infections should initially be treated with
any of the antibiotics recommended for prophylaxis (Grade
B).
 RECURRENT UTI
• Diagnostics:
– Routine screening is NOT recommended (Grade E).
– Indications for screening:
• Gross hematuria during UTI episode
• Obstructive symptoms
• Clinical impression of persistent infection
• Infection with urea-splitting bacteria
• History of pyelonephritis
• History of or symptoms suggestive of urolithiasis
• History of childhood UTI
• Elevated serum creatinine (Grade C)
 RECURRENT UTI
• Choice of screening procedure
– Combined renal ultrasound and a plain abdominal
radiograph (Grade B).
 COMPLICATED UTI
• Definition:
– Significant bacteriuria, in the setting of functional or
anatomic abnormalities of the urinary tract or kidneys.
– 100,000 cfu/ml may be significant in catheterized patients.
 COMPLICATED UTI
• Conditions that define complicated UTI

Presence of an indwelling urinary catheter or intermittent catheterization

Incomplete empyting of the bladder with >100 ml retained urine post- voiding
Obstructive uropathy due to bladder outlet obstruction, calculus and other causes
Vesicoureteral reflux and other urologic abnormalities including surgically created
abnormalities
 COMPLICATED UTI
• Conditions that define complicated UTI
Azotemia due to intrinsic renal disease
Renal transplantation
Diabetes mellitus
UTI caused by unusual pathogens or drug resistant pathogens
UTI in males except I young males presenting with exclusively with lower UTI symptoms
 COMPLICATED UTI
• Diagnostics
– Gram stain, culture and sensitivity testing must always be
obtained before the initiation of any treatment (Grade B).
 COMPLICATED UTI
• Indication for admission
– Patients with complicated UTI with
• marked debility
• signs of sepsis
• uncertainty in diagnosis
• concern about adherence to treatment
• who are unable to maintain oral hydration or take oral
medications
 COMPLICATED UTI
• Treatment
– For mild to moderate illness:
• Oral fluoroquinolones are recommended (Grade A).
– For severe illness:
• Broad spectrum parenteral antibiotics (Grade C).
 COMPLICATED UTI
• Antibiotics that may be used as empiric therapy for
complicated UTI
Oral Regimen
Ciprofloxacin 250-500 mg BID x 14 days
Norfloxacin 400 mg BID x 14 days
Ofloxacin 200 mg BID x 14 days
Levofloxacin 250-500 mg OD x1 0-14 days
 COMPLICATED UTI
Parenteral Regimen
Ampicillin 1 g q6h + gentamicin 3 mg/kg/day q24h
Ampicillin-sulbactam 1.5 g to 3 g q6h
Ceftazidime 1-2 g q8h
Ceftriaxone 1-2g q24h
Imipenem-cilastin 250-500mg q6-8h
Piperacillin-Tazobactam 2.25 g q6h
Ciprofloxacin 200-400 mg q12h
Ofloxacin 200-400 mg q12h IV
Levofloxacin 500 mg q24h IV
 COMPLICATED UTI
• Duration of treatment
– Antibiotics are modified accdg to results of urine culture
and sensitivity test.
– Started with parenteral regimen may be switched to oral
therapy upon improvement.
– At least 7-14 days of therapy is recommended (Grade B).
 COMPLICATED UTI
• Post treatment tests
– repeat urine culture 1-2 weeks after completion of
medications (Grade C).
– Further work-up to identify and correct the anatomical,
functional or metabolic abnormality is indicated (Grade C).
 UTI IN MEN
• UNCOMPLICATED CYSTITIS IN YOUNG MEN
– UTI in men generally considered complicated
– 1st episode of symptomatic lower UTI occurring in a young
(15-40 yo) healthy sexually active men with no clinical or
historical evidence of a structural or functional urologic
abnormality is considered as uncomplicated UTI.
 UTI IN MEN
• Diagnostics
– Urinalysis and urine culture.
– Pre-treatment urine culture should be performed routinely
in all men with UTI (Grade C).
– Routine urologic evaluation and use of imaging
procedures are NOT recommended (Grade C).
– Significant pyuria >/= 10 wbc/mm3 or >/= 5 wbc/hpf in a
clean catch midstream urine specimen (Grade C).
 UTI IN MEN
• Treatment
– 7-day antibiotic regimen is recommended (Grade C).
– TMP-SMX or fluoroquinolones may be used depending on
prevailing susceptibility patterns (Grade C).
Thank you! 