6.

17 Urinary tract infections

110

Bacterial urinary tract infections (UTI)

Management of patients WITHOUT a urinary catheter
NOTE: Ciprooxacin is not recommended for empiric treatment for in-patients with non-catheter associated UTI at JHH due to the low rate of E. coli
ViL
Category
Asymptomatic
bacteriuria

Denition
Positive urine culture  100,000 CFU/mL
with no signs or symptoms

Empiric treatment
i>iii>i\
U*i}>
U
L`i}>}VVi`i
U*i>>>
U iiV

Notes
U"L>}iVi>>V>i
not recommended
U
LV``iVi>i>>VL>Vi>
prevent subsequent development of UTIs
U/ii>iViv>>VL>Vi>
}\xii>>i]
i>>i]{x}iV>i
i`i>`i`>Lii

Acute cystitis

Signs and symptoms (e.g. dysuria, urgency

frequency, suprapubic pain)
AND pyuria (>10 WBC/hpf )
AND positive urine culture 100,000
CFU/mL
UUncomplicated: female, no urologic
abnormalities, no stones, no catheter
UComplicated: male gender, possible
stones, urologic abnormalities, pregnancy

1VV>i`\
U v>>VL`) 100 mg PO Q12H for
x`> "/>i

x
OR
U
i>ix}*"+vx`>
OR
U
iv`i}*"+vx`>
OR
U
iv`}*"+vx`>
OR
U/*-8->L*"+v`>
OR
U6\
iv>}6+nv`>

V>i`\
U->ii}i>>LiiVi`>
q{`>

U1/i>i>`>V`ii`VV>i`
UTIs in men in the absence of obstructive pathology
(e.g. BPH, stones, strictures) are uncommon. Please
critically evaluate your diagnosis of UTI in male patients.
U">i>ivii`>``Li}ii
patient is unable to tolerate oral therapy
Uv6Li>>V>>ii`iV>v`>]
additional therapy is needed for uncomplicated cystitis
Uv6Li>>V>>ii`iV>v`>
or treating complicated cystitis, the patient can be
switched to an appropriate oral beta-lactam and duration
of IV therapy should be counted towards total duration
of therapy
U">vVV>Lii`vViLiv>
negative MDR organisms (susceptibilities must be
requested)

Category
Acute
pyelonephritis

Denition
Signs and symptoms (e.g. fever, ank pain)
AND pyuria
AND positive urine culture 100,000
CFU/mL
Many patients will have other evidence of
upper tract disease (i.e. leukocytosis,
WBC casts, or abnormalities upon imaging)

Urosepsis

SIRS with urinary source of infection

Empiric treatment
U
iv>i}6+{
OR
U >ii}6+{vv - 
OR
U*
>i}\
i>}6+n",
Gentamicin (see dosing section, p. 147)
U>\q{`>
Hospitalized > 48H
U
ivii}6+n
OR
U*
>i}\
i>}6+n",
Gentamicin (see dosing section, p. 147)
U>\q{`>
U
ivii}6+n
OR
U*
>i}\
i>}6+n
Gentamicin (see dosing section, p. 147)
U>\q`>

Notes
U">i`i>`Lii`v}>
susceptible
U>viV6i>`LiVi`
towards total duration of therapy
">i`i>v}>ViLi\
U
y>Vx}*"+v`>
U/*-8-*"+v`>
U
iv`i{}*"+v{`>
U">vVV>LiV`ii`vViLiv
Gram-negative MDR organisms (susceptibilities must be
requested). Consult ID Pharmacist for dosing.

U">
y>V/*-8>iiVii
bioavailability and should be used as step-down therapy
if organism is susceptible
U">Li>>V>`Lii`vL>Vii>
due to inadequate blood concentrations
U>viV6i>`LiVi`
towards total duration of therapy

111
6.17 Urinary tract infections

6.17 Urinary tract infections

DIAGNOSIS
Specimen collection\/ii>>i>`LiVi>i`>
antiseptic cloth and the urine sample should be collected midstream
or obtained by fresh catheterization. Specimens collected using
a drainage bag or taken from a collection hat are not reliable and
should not be sent.
Interpretation of the urinalysis (U/A) and urine culture
U1>>`iViLiiii`}ii
context of symptoms
UUrinalysis/microscopy:
UV
U i`V>iL>Vi>ii
UiViii>i`V>iiL`Viii
U >Vi>\iiVivL>Vi>>`Li
interpreted with caution and is not generally useful
U*>iii>iViii>i\7
v
>27 WBC/microliter
U1iVi\
Uv1
i}>iv>]iVi>ii
contamination
U>i1/>i100,000 colonies of a
uropathogen. Situations in which lower colony counts may be
}wV>V`i\>i>i>i>`>LV>i
time of culture, symptomatic young women, suprapubic aspiration,
and men with pyuria.
TREATMENT NOTES
U*>iiii}vi}>iiVi>i
with asymptomatic bacteriuria usually requires no treatment. If
pyuria persists consider other causes (e.g. interstitial nephritis or
cystitis, fastidious organisms).
UiVi1
>i>>i`v}}
symptoms. They should NOT be acquired routinely to monitor
response to therapy.
U-ii{v`Vvi>iv6, >`i>
concentrations of antibiotics.

112

Category
Asymptomatic
bacteriuria

Denition
Positive urine culture
 100,000 CFU/mL
with no signs or
symptoms of infection

Empiric treatment
Remove the catheter
i>iii>i\
U*i}>
U
L`i}>}VVi`i
U*i>>>
"/ \L>}
U iiV
routine cultures in
Antibiotics do not decrease asymptomatic
asymptomatic patients bacteriuria or prevent subsequent development
is not recommended
of UTI
Signs and symptoms
CatheterU,iiV>iiiLi
associated UTI (fever with no other
Patient stable with no evidence of upper tract
source is the most
(CA-UTI)
`i>i\
V>i> UvV>iiii`]V`iLi>>i
also have suprapubic
OR
or ank pain)
U >ii}6+{
AND pyuria (10
OR
WBC/hpf)
U
iv>i}6+{
AND positive urine
OR
culture 1,000
U
y>Vx}*" {}6+
CFU/mL (see
(avoid in pregnancy and in patients with prior
information below
exposure to quinolones)
regarding signicant
U>\iiLi
colony counts)
Patient severely ill, with evidence of upper tract
disease, or hospitalized {n\
U
ivii}6+n
OR
U*
>i}\
i>}6+n
U>\iiLi
Urosepsis in a SIRS with urinary
U*i>V>L>V>x}6+
source and
patient with
If prior urine culture data are available, tailor
nephrostomy tubes
nephrostomy
therapy based on those results
tubes

DIAGNOSIS
-iViViV\ The urine sample should be drawn from the
catheter port using aseptic technique, NOT from the urine collection
bag. In patients with long term catheters ( 2 weeks), replace the
catheter before collecting a specimen. Urine should be collected before
antibiotics are started.
-\ Catheterized patients usually lack typical UTI symptoms.
-V>Li

1/V`i\
U ivii}iVi
U ii`i]>>i]i>}iVi
U
6
i`ii]y>>]iV`Vv
U
Vii>>
Interpretation of the urinalysis (U/A) and urine culture
U*>\iiiViv>V>ii]>`iVi>i
the presence of symptomatic CA-UTI and must be interpreted based
on the clinical scenario. The absence of pyuria suggests an alternative
diagnosis.
U*iiVi\ 1,000 colonies
113

6.17 Urinary tract infections

Management of patients WITH a urinary catheter

6.17 Urinary tract infections

DURATION
The duration of treatment has not been well studied for CA-UTI and
optimal duration is not known.
U`>viv
Uq{`>v`i>i`ii
U`>vV>iiii`vi>i>i 65 years with lower
tract infection.
TREATMENT NOTES
U,iiiV>iiiiiLi
U,i>ViV>ii>>iLii 2 weeks if still indicated
U*>VV>LV>iivV>iii>i>Vii
are NOT recommended due to low incidence of complications and
concern for development of resistance.
U
>ii}>`Lii`i
Treatment of Enterococci
U
>E. faecalis isolates are susceptible to Amoxicillin 500 mg
PO TID OR Ampicillin 1 g IV Q6H and should be treated with these
>}i>i*
>i}\ v>>VL`)
}*"+` "/i>i

x
UE. faecium (often Vancomycin resistant)
U v>>VL`) 100 mg PO Q12H if susceptible (do NOT
use in patients with CrCl  50 mL/min).
U/i>VVix}*"+vViLi
UvV}*"Vivvi>iV>iiV>ii
ii`>iV>LvViL
Ui`}*" ",vV}*"iiq`>
(max 21 days) if complicated UTI or catheter can not be removed
Renal excretion/concentration of selected antibiotics
Good (60%): aminoglycosides, Amoxicillin, Amoxicillin/clavulanate,
Fosfomycin, Cefazolin, Cefepime, Cephelexin, Ciprooxacin,
Colistin, Ertapenem, Trimethoprim/sulfamethoxazole, Vancomycin,
Amphotericin B, Fluconazole, Flucytosine
Variable (30-60%):
iv`i]i`]VVi
qxx]
iv>i]/i>VViH
Poor (<30%): Azithromycin, Clindamycin, Moxioxacin, Oxacillin,
Tigecycline, Micafungin, Posaconazole, Voriconazole
,iviiVi\
*>>`>V>ii\
Vi`x\
IDSA Guidelines for treatment of uncomplicated acute bacterial cystitis and
iii\
viV\{x
-
`iivi>iv

1/\
viVx\xq

114

Oropharyngeal disease (thrush)

Initial treatment
U
>i}Vixi>`>
OR
U >ix]x{i>`>
Recurrent or intractable disease
UV>iq}*"Vi`>
Duration: xq`>
NOTE: If refractory to Fluconazole consider fungal culture and
susceptibilities
Esophageal candidiasis
Initial treatment
UV>iq{}6*"Vi`>
Duration: {q`>
Relapse
UV>i{qn}6*"Vi`>
Refractory to Fluconazole 800 mg daily (fungal culture and
susceptibilities are recommended)
UV>v}x}6Vi`>
OR
U
iV q}}6Vi`>
OR
U">i>\>V>i>}`>
Duration: {q`>
Candiduria
U1>V>iii>iiiV>``>{vV>i
TREATMENT
Asymptomatic cystitis
U/i>>`V>i`
U
`iiv}V`iii}i`i
>VV\
U iiV>i
U,i>>>
U1>LV>L>1>V
U7iiVii`i}VVi`i

115

6.18 Candidiasis in the non-neutropenic patient

Candidiasis in the non-neutropenic patient

6.18 Candidiasis in the non-neutropenic patient

Symptomatic cystitis
Preferred therapy
UV>i}6*"Vi`>
Duration:q{`>
Fluconazole-resistant organism suspected or conrmed
U
iV }}6Vi`>
Duration:q`>
Pyelonephritis
NOTE: Candida pyelonephritis is usually secondary to hematogenous
spread except for patients with renal transplant or abnormalities of the
urogenital tract.
Preferred therapy
UV>iq{}6*"Vi`>
Duration: 14 days
Fluconazole-resistant organism suspected or conrmed
U
iV xq}}6Vi`>
OR
UV>v}}6Vi`>
Duration: 14 days
TREATMENT NOTES
U,ii>V>iivLi
U/i>vV>``>iiiV]
1V>iii`
patient has not been shown to be benecial and promotes resistance.
U
i, Voriconazole, Itraconazole, and Posaconazole are not
recommended due to poor penetration into the urinary tract.
UV>v}ii>iii]L`iii>i
renal tissue.
U
iV L>``i>i>iiVi`i`

116