1

Urinary Tract Infection Antibiotic Protocol

Outpatient Management
Cystitis Women, no underlying factors Trimethoprim-sulfamethoxazole DS po bid for 3 days Alternatives Gatifloxacin (Tequin) 200 mg po qd for 3 days OR Nitrofurantoin SR (Macrobid) 100 mg po bid for 7 days Underlying factors, (men, diabetes, age >65 years, women with complicating factors) Trimethoprim-sulfamethoxazole DS po bid for 7 days Alternatives Gatifloxacin (Tequin) 400 mg po qd for 7 days OR Nitrofurantoin SR (Macrobid) 100 mg po bid for 7 days Pyelonephritis (Mild) Gatifloxacin (Tequin) 400 mg po qd for 10-14 days OR Trimethoprim-sulfamethoxazole DS po bid for 14 days if organism known to be sensitive Consider giving either ceftriaxone 1 gm IM OR gentamicin 160 mg IM (80 mg in each hip or arm) in the clinic times one dose before going home.

*These recommendations may not be appropriate for all clinical situations. Decisions must be based on the professional judgment of the clinician and consideration of the individual patient circumstances and available resources.

Emergency Department Management Patient being discharged home

Cystitis Women, no underlying factors Trimethoprim-sulfamethoxazole DS po bid for 3 days Alternatives Gatifloxacin (Tequin) 200 mg po qd for 3 days OR Nitrofurantoin SR (Macrobid) 100 mg po bid for 7 days Underlying factors, (men, diabetes, age >65 years, women with complicating factors) Trimethoprim-sulfamethoxazole DS po bid for 7 days Alternatives Gatifloxacin (Tequin) 400 mg po qd for 7 days OR Nitrofurantoin SR (Macrobid) 100 mg po bid for 7 days Pyelonephritis (Mild)

Gentamicin 5 mg/kg IV times one dose, then Gatifloxacin (Tequin) 400 mg po qd for 10-14 days OR Trimethoprim-sulfamethoxazole DS po bid for 14 days if organism known to be sensitive

Emergency Department Management Patient being admitted to Hospital

See Inpatient Management

*These recommendations may not be appropriate for all clinical situations. Decisions must be based on the professional judgment of the clinician and consideration of the individual patient circumstances and available resources.

Inpatient Management

Urinary Tract infection

Gentamicin 5 mg/kg IV as single dose in ED or on Hospital floor. If suspect Enterococcus or gram-positive cocci are identified on gram stain, give Ampicillin 2 gm IV as a single dose in ED or on Hospital floor then continue with Ampicillin 1 gm IV q6h. Reassess patient within 24 hours if clinically better ( fever) discontinue intravenous antibiotics and begin oral therapy with TMP/SMZ DS bid or Gatifloxacin (Tequin) 400 mg qd If NOT clinically better; repeat Gentamicin dose 24 hours after 1st dose and continue Ampicillin if used. Reassess patient the next day for conversion to oral therapy. Total duration of therapy 10-14 days All doses should be adjusted for renal function.

Pyelonephritis (severe)

Gentamicin 5 mg/kg IV as single dose in ED or on Hospital floor, repeat dose in 24 hours. If suspect Enterococcus or gram-positive cocci identified on gram stain, give Ampicillin 2 gm IV as a single dose in ED or on Hospital floor then continue with Ampicillin 1 gm IV q6h. Reassess patient on rounds Day 1 If significantly improved, consider switching to oral Gatifloxacin (Tequin) 400 mg qd Reassess patient on rounds Day 2 If clinically improved (fever, WBC) discontinue intravenous antibiotics and switch to oral therapy with Gatifloxacin (Tequin) 400 mg qd. Other oral agents could be used based on susceptibility data, (i.e. TMP/SMZ DS) If NOT clinically improved, continue IV antibiotics. Additionally, reassess antibiotic selection based on susceptibility data. Total duration of therapy 14 days All doses should be adjusted for renal function.

*These recommendations may not be appropriate for all clinical situations. Decisions must be based on the professional judgment of the clinician and consideration of the individual patient circumstances and available resources.

Urosepsis admission to floor

Gentamicin 5 mg/kg IV as single dose in ED or on Hospital floor; repeat dose q24h. If suspect Enterococcus or gram-positive cocci identified on gram stain, give Ampicillin 2 gm IV as a single dose in ED or on Hospital floor then continue with Ampicillin 1 gm IV q6h. Reassess patient on rounds Day 1 Reassess patient on rounds Day 2 If clinically improved (fever, WBC) discontinue intravenous antibiotics and switch to oral therapy with Gatifloxacin (Tequin) 400 mg qd. Other oral agents could be used based on susceptibility data, (i.e. TMP/SMZ DS) If NOT clinically improved, continue IV antibiotics. Additionally, reassess antibiotic selection based on susceptibility data. Total duration of therapy 14 days All doses should be adjusted for renal function.

Urosepsis admission to ICU

Gentamicin 5 mg/kg IV q24h and Timentin 3.1 gm IV q6h

Alternative

Ciprofloxacin 400 mg IV q12h and Timentin 3.1 gm IV q6h

Aminoglycoside Once Daily Dosing Est CrCl (ml/min) 100 90 80 70 60 50 40 30 20 Dose using DW (mg/kg) 5 5 5 4 4 3.5 2.5 2.5 4 Dosage Interval (Hrs) 24 24 24 24 24 24 24 24 48

*These recommendations may not be appropriate for all clinical situations. Decisions must be based on the professional judgment of the clinician and consideration of the individual patient circumstances and available resources.

References
1. Warren JW, Abrutyn E, Hebel JR, Johnson JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis 1999;29:745-758. 2. Anderson RU. Management of lower urinary tract infections and cystitis. Urol Clin N Am. 1999;26:729-735. 3. Roberts JA. Management of pyelonephritis and upper urinary tract infections. Urol Clin N Am. 1999;26:753-763.

C:UTI protocol.doc 6/15/02

*These recommendations may not be appropriate for all clinical situations. Decisions must be based on the professional judgment of the clinician and consideration of the individual patient circumstances and available resources.