Infecciones Urinarias Agudas Complicadas (Incluyendo Pielonefritis) en Adultos - UpToDate

20/9/22, 00:14 Infecciones urinarias agudas complicadas (incluyendo pielonefritis) en adultos - UpToDate
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Infecciones agudas complicadas del tracto urinario

(incluyendo pielonefritis) en adultos
Autor: Kalpana Gupta, MD, MPH
Redactor de sección: Stephen B. Calderwood, MD
Redactor adjunto: Dra. Allyson Bloom
Todos los temas se actualizan a medida que se dispone de nueva evidencia y se completa nuestro proceso de
revisión por pares .
Revisión de la literatura actual hasta: agosto de 2022. | Última actualización de este tema: 12 de agosto de
2022.
INTRODUCCIÓN
Las infecciones del tracto urinario (ITU) incluyen cistitis (infección de la vejiga/tracto urinario
inferior) y pielonefritis (infección del riñón/tracto urinario superior). La patogenia de la UTI
comienza con la colonización del introito vaginal o el meato uretral por uropatógenos de la
flora fecal, seguida de la ascensión a través de la uretra hacia la vejiga. La pielonefritis se
desarrolla cuando los patógenos ascienden a los riñones a través de los uréteres. La
pielonefritis también puede ser causada por la siembra de los riñones por bacteriemia. Es
posible que algunos casos de pielonefritis estén asociados con la siembra de bacterias en los
vasos linfáticos en los riñones.
Este tema revisará el abordaje de adultos con UTI complicada aguda, que definimos como una
UTI que posiblemente se ha extendido más allá de la vejiga (es decir, UTI con fiebre u otros
síntomas sistémicos, pielonefritis sospechada o documentada e UTI con sepsis o bacteriemia).
Por el contrario, cuando hay síntomas de cistitis en ausencia de fiebre, dolor en el costado,
sensibilidad en el ángulo costovertebral y otros signos de enfermedad sistémica, consideramos
esta cistitis aguda simple. Este enfoque para categorizar las ITU ( tabla 1 ) difiere de otras
convenciones, como se analiza en detalle a continuación.
Nuestros enfoques para el diagnóstico y tratamiento de la cistitis simple aguda (es decir,
síntomas de cistitis en ausencia de fiebre, dolor en el costado, sensibilidad en el ángulo
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costovertebral y otros signos de enfermedad sistémica) y las infecciones urinarias en

poblaciones especiales se analizan en otros lugares:
● (Consulte "Cistitis aguda simple en mujeres" .)

● (Consulte "Cistitis simple aguda en hombres adultos" .)
● (Ver "Infecciones del tracto urinario y bacteriuria asintomática en el embarazo" .)
● (Consulte "Infección del tracto urinario asociada al catéter en adultos" .)
● (Consulte "Infección del tracto urinario en receptores de trasplante de riñón" .)
● (Ver "Cistitis simple recurrente en mujeres" .)
Asymptomatic bacteriuria is also discussed in detail elsewhere. (See "Asymptomatic bacteriuria

in adults".)
UTI in children is also discussed separately. (See "Urinary tract infections in children:
Epidemiology and risk factors" and "Urinary tract infections in children: Long-term
management and prevention" and "Urinary tract infections in infants and children older than
one month: Clinical features and diagnosis" and "Urinary tract infections in infants older than
one month and young children: Acute management, imaging, and prognosis".)
TERMINOLOGY
We use the term acute complicated urinary tract infection (UTI) to refer to an acute UTI with any
of the following features, which suggest that the infection extends beyond the bladder
( table 1):
● Fever (>99.9°F/37.7°C) – This temperature threshold is not well defined and should be
individualized, taking into account baseline temperature, other potential contributors to
an elevated temperature, and the risk of poor outcomes should empiric antimicrobial
therapy be inappropriate.
● Other signs or symptoms of systemic illness (including chills or rigors, significant fatigue
or malaise beyond baseline).
● Flank pain.
● Costovertebral angle tenderness.
● Pelvic or perineal pain in men, which can suggest accompanying prostatitis. (See "Acute
bacterial prostatitis" and "Chronic bacterial prostatitis".)
By this definition, pyelonephritis is a complicated UTI, regardless of patient characteristics. In

the absence of any of these symptoms, we consider patients with UTI to have acute simple
cystitis and manage the patient differently. (See "Acute simple cystitis in women" and "Acute
simple cystitis in adult males".)
We do not automatically consider patients with underlying urologic abnormalities (such as

nephrolithiasis, strictures, stents, or urinary diversions), immunocompromising conditions
(such as neutropenia or advanced HIV infection), or poorly controlled diabetes mellitus to have
a complicated UTI if they have no concerning symptoms for upper tract or systemic infection.
However, such patients can be at higher risk for more serious infection and have not
traditionally been included in studies evaluating the antibiotic regimens we typically use for
acute simple cystitis. Thus, we follow such patients more closely and/or have a low threshold to
manage them as complicated UTI (eg, if they have subtle signs or symptoms that could be
suggestive of more extensive infection). Many patients with significant urologic abnormalities
come to clinical attention for UTI because of signs or symptoms consistent with complicated
UTI as defined here (rather than features of simple cystitis alone).
We also do not automatically consider men to have acute complicated UTI in the absence of
concerning symptoms for upper tract or systemic infection. However, the possibility of prostatic
involvement should always be considered in men, and this is incorporated into our approach to
men with apparent simple cystitis. (See "Acute simple cystitis in adult males".)
Certain populations, such as pregnant women and renal transplant recipients, have unique
management considerations and thus are not included in the above categorization. These
populations are discussed elsewhere. (See "Urinary tract infections and asymptomatic
bacteriuria in pregnancy" and "Urinary tract infection in kidney transplant recipients".)
These definitions of acute simple cystitis and complicated UTI are different from other
categorizations, which themselves are somewhat variable. Specifically, cystitis or pyelonephritis
in a nonpregnant premenopausal woman without underlying urologic abnormalities has
traditionally been termed acute uncomplicated UTI [1], and complicated UTI has been defined,
for the purposes of treatment trials, as cystitis or pyelonephritis in a patient with underlying
urologic abnormalities. Individuals who do not fit into either category have often been treated
as having a complicated UTI by default. We favor an approach to treatment based on the extent
of infection and severity of illness. Since complicated UTI, as defined here, is a more serious
infection than simple cystitis, the efficacy of an antimicrobial agent is of greater importance,
and certain agents used for simple cystitis should not be used for complicated UTI because they
do not achieve adequate levels in tissue, which may be important for cure. Risk for infection
with drug-resistant organisms is a consideration in antibiotic selection for both simple cystitis
and acute complicated UTI.
MICROBIOLOGY
Escherichia coli is the most frequent cause of acute complicated urinary tract infections (UTIs).
Other uropathogens include other Enterobacterales (such as Klebsiella spp and Proteus spp),
Pseudomonas, enterococci, and staphylococci (methicillin-sensitive Staphylococcus aureus [MSSA]
and methicillin-resistant S. aureus [MRSA]) [2,3]. The prevalence of particular pathogens
depends partially on the host. As examples, Pseudomonas is more common in patients with
health care exposures or instrumentation. Staphylococcus saprophyticus is an occasional cause
of pyelonephritis in young, otherwise healthy women. UTI due to Candida spp is discussed in
detail elsewhere. (See "Candida infections of the bladder and kidneys".)
Risk factors for UTI with resistant organisms include recent broad-spectrum antimicrobial use,
health care exposures, and travel to parts of the world where multidrug-resistant organisms are
prevalent [4-8] ( table 2).
Increasing rates of resistance in uropathogens have been reported globally. As an example, in

the United States, one study documented a threefold increase in the prevalence of extended-
spectrum beta-lactamase (ESBL)-producing Enterobacterales among hospitalized patients with
UTIs from 2000 to 2009 [9]. In another study of patients with pyelonephritis presenting to
emergency departments across the United States, approximately 6 percent of the 453 E. coli
isolates produced ESBL, although rates varied by region and complicating features [10]. In
particular, a specific strain of E. coli, sequence type 131 (ST131), has emerged globally as a
major cause of fluoroquinolone-resistant and ESBL-producing E. coli urinary tract infections [11].
In one study of E. coli clinical isolates from extraintestinal sites, predominantly urine, collected
at Veterans Affairs (VA) laboratories across the United States, the ST131 clone accounted for the
majority of fluoroquinolone-resistant and ESBL isolates and was calculated to account for 28
percent of all VA E. coli isolates nationwide [12]. Carbapenem resistance among
Enterobacterales has also increased. (See "Extended-spectrum beta-lactamases", section on
'Epidemiology' and "Overview of carbapenemase-producing gram-negative bacilli", section on
'Epidemiology'.)
CLINICAL MANIFESTATIONS
Typical presentation — The clinical spectrum of acute complicated urinary tract infection (UTI)
encompasses both cystitis with complicating features and pyelonephritis:
● Symptoms and signs of cystitis include dysuria, urinary frequency and urgency,
suprapubic pain, and hematuria. Patients with acute complicated UTI also have fever or
other features of systemic illness (including chills, rigors, or marked fatigue or malaise
beyond baseline), which suggest that infection has extended beyond the bladder.
● Symptoms and signs of pyelonephritis classically include fever, chills, flank pain,
costovertebral angle tenderness, and nausea/vomiting [13]. Symptoms of cystitis are often
but not universally present. Atypical symptoms have also been described, with some
patients complaining of pain in the epigastrium or lower abdomen.
For men, the clinical spectrum of UTI includes prostatitis, which should be considered in men
presenting with cystitis symptoms that are recurrent or are accompanied by pelvic or perineal
pain. (See "Acute bacterial prostatitis" and "Chronic bacterial prostatitis".)
Not all patients with acute complicated UTI present with clear symptoms localizing to the
urinary tract. As an example, patients with spinal cord injury and neurogenic bladder can
present with autonomic dysreflexia and increased spasticity. Older or debilitated patients may
present with more generalized signs or symptoms of infection (eg, fever and chills) without
clear symptoms localizing to the urinary tract.
Pyuria is present in almost all patients with UTI.
Complications — Patients with acute complicated UTI can also present with bacteremia, sepsis,
multiple organ system dysfunction, shock, and/or acute renal failure. This is more likely to occur
in patients with urinary tract obstruction, recent urinary tract instrumentation, or other urinary
tract abnormalities, and in patients who are older adults or have diabetes mellitus.
Acute pyelonephritis can also be complicated by progression of the upper urinary tract infection
to renal corticomedullary abscess, perinephric abscess, emphysematous pyelonephritis, or
papillary necrosis. Risk factors for such complications include urinary tract obstruction and
diabetes mellitus (particularly for emphysematous pyelonephritis and papillary necrosis). (See
"Renal and perinephric abscess" and "Emphysematous urinary tract infections".)
Xanthogranulomatous pyelonephritis is a rare variant of pyelonephritis in which there is

massive destruction of the kidney by granulomatous tissue. Most cases occur in the setting of
obstruction due to infected renal stones. Affected patients can present with weeks to months of
insidious and nonspecific signs and symptoms, such as malaise, fatigue, nausea, or abdominal
pain. This condition is discussed in detail elsewhere. (See "Xanthogranulomatous
pyelonephritis".)
DIAGNOSTIC APPROACH
Evaluation — Acute complicated urinary tract infection (UTI) should be suspected in patients

with dysuria, urinary frequency or urgency, or suprapubic pain who also have fever, chills, flank
pain, pelvic or perineal pain (in men), or who otherwise appear clinically ill. Acute
pyelonephritis, specifically, should be suspected in patients presenting with fever and flank
pain, even in the absence of typical symptoms of cystitis. Acute complicated UTI is also often
suspected in patients with nonlocalizing fever or sepsis. Evaluation includes examination to
assess for other causes of illness and urine studies.
Physical exam should assess for costovertebral angle, abdominal, and suprapubic tenderness.
Among sexually active young women, a pelvic examination may be warranted, particularly if
symptoms are not convincing for a UTI, to evaluate for cervical motion or uterine tenderness,
which would be suggestive of pelvic inflammatory disease (see "Pelvic inflammatory disease:
Clinical manifestations and diagnosis", section on 'Evaluation'). Among men with symptoms of
pelvic or perineal pain, cautious digital rectal examination may be warranted to evaluate for a
tender or edematous prostate that would suggest acute prostatitis. (See "Acute bacterial
prostatitis".)
UTI is often suspected in older or debilitated patients who have nonspecific signs or symptoms,
such as falls, change in functional status, and change in mental status. However, growing
evidence indicates these are not reliable predictors of bacteriuria or UTI [14,15] and suggests
that treatment for UTI in this setting is not associated with improved outcomes [16-18]. When
these nonspecific signs or symptoms are accompanied by signs or symptoms of systemic
infection or pyelonephritis, evaluation for acute complicated UTI with urine studies, in addition
to a general infectious workup, is appropriate. (See "Diagnosis of delirium and confusional
states", section on 'Diagnostic tests'.)
For all patients with suspected acute complicated UTI, we send urine for both urinalysis (either
by microscopy or by dipstick) and culture with susceptibility testing. Urinalysis results inform
the diagnosis. Since pyuria is present in almost all patients with UTI; its absence suggests an
alternative diagnosis, particularly in patients who present with nonspecific symptoms. White
cell casts, in particular, suggest a renal origin for pyuria. However, pyuria and bacteriuria may
occasionally be absent if the infection does not communicate with the collecting system or if
the collecting system is obstructed. Growth of bacteria on urine culture also supports the
diagnosis of UTI, and susceptibility testing is essential to ensuring appropriate antimicrobial
treatment. (See 'Management' below.)
Issues related to urine collection and testing as well as interpretation of urine culture colony
counts are found elsewhere. (See "Sampling and evaluation of voided urine in the diagnosis of
urinary tract infection in adults".)
Pregnancy testing is appropriate in women of childbearing potential when the possibility of

pregnancy cannot be reasonably excluded by history alone. Blood tests, such as general
chemistry and complete blood counts, are not generally necessary unless the patient is
hospitalized. Blood cultures are warranted for those who present with sepsis or severe illness or
who have S. aureus isolated from the urine. (See 'Regimen selection' below.)
Imaging — Most patients with acute complicated UTI do not warrant imaging studies for
diagnosis or management. Imaging is generally reserved for those who are severely ill, have
persistent clinical symptoms despite 48 to 72 hours of appropriate antimicrobial therapy, or
have suspected urinary tract obstruction (eg, if the renal function has declined below baseline
or if there is a precipitous decline in the urinary output). Imaging is also appropriate in patients
who have recurrent symptoms within a few weeks of treatment [19].
The main objective of imaging is to evaluate for a process that may delay response to therapy
or warrant intervention, such as a calculus or obstruction, or to diagnose a complication of
infection, such as a renal or perinephric abscess [19]. Imaging should be obtained urgently in
patients with sepsis or septic shock to identify any evidence of obstruction or abscess that
requires urgent source control.
Computed tomography (CT) scanning of the abdomen and pelvis (with and without contrast) is
generally the study of choice to detect anatomic or physiologic factors associated with acute
complicated UTI; it is more sensitive than excretory urography or renal ultrasound for detecting
renal abnormalities predisposing to or caused by infection and in delineating the extent of the
disease [20,21]. CT without contrast has become the standard radiographic study for
demonstrating calculi, gas-forming infections, hemorrhage, obstruction, and abscesses [21].
Contrast is needed to demonstrate alterations in renal perfusion. CT findings of pyelonephritis
include localized hypodense lesions due to ischemia induced by marked neutrophilic infiltration
and edema ( image 1A-C) [20,22]. The CT can be normal in patients with mild infection [23].
Renal ultrasound is appropriate in patients for whom exposure to contrast or radiation is

undesirable [24]. Magnetic resonance imaging (MRI) is not advantageous over CT except when
avoidance of contrast dye or ionizing radiation is warranted [25]. (See "Contrast-associated and
contrast-induced acute kidney injury: Clinical features, diagnosis, and management" and
"Prevention of contrast-associated acute kidney injury related to angiography".)
Resolution of radiographic hypodensities may lag behind clinical improvement by up to three

months [20,22,26].
Diagnosis — The diagnosis of acute complicated UTI is made in the following clinical scenarios:
● Symptoms of cystitis (dysuria, urinary urgency, and/or urinary frequency) along with fever
(>99.9ºF/37.7ºC) or other signs or symptoms of systemic illness, such as chills, rigors, or
acute mental status changes. In such cases, pyuria and bacteriuria support the diagnosis.
● Flank pain and/or costovertebral angle tenderness in the setting of pyuria and bacteriuria.
This is suggestive of pyelonephritis. Fever and typical symptoms of cystitis are usually
present, but their absence does not rule out the diagnosis. CT findings that support the
diagnosis include low attenuation extending to the renal capsule on contrast
enhancement with or without swelling and complications such as renal abscesses.
However, a normal CT does not rule out the possibility of mild pyelonephritis.
● Fever or sepsis without localizing symptoms in the setting of pyuria and bacteriuria may
be attributed to UTI if other causes have been ruled out. Careful clinical assessment is
necessary. The diagnosis of acute complicated UTI is unlikely if pyuria is absent.
The presence of bacteriuria (≥105 colony-forming units/mL of a uropathogen) with or without

pyuria in the absence of any symptom that could be attributable to a UTI is called asymptomatic
bacteriuria and generally does not warrant treatment in nonpregnant patients who are not
undergoing urologic surgery. (See "Asymptomatic bacteriuria in adults".)
The diagnosis of UTI in a patient with an indwelling urinary catheter is discussed in further
detail elsewhere. (See "Catheter-associated urinary tract infection in adults", section on
'Diagnosis'.)
The diagnosis of bacterial prostatitis in men, which can present with similar symptoms as
complicated UTI, is discussed separately. (See "Acute bacterial prostatitis", section on 'Diagnosis'
and "Chronic bacterial prostatitis", section on 'Diagnosis'.)
MANAGEMENT
Empiric antimicrobial therapy should be initiated promptly, taking into account risk factors for
drug resistance, including previous antimicrobial use and results of recent urine cultures, with
subsequent adjustment guided by antimicrobial susceptibility data. Urology should be
consulted to address anatomic abnormalities if these are suspected or identified on imaging.
Approach to management of patients diagnosed with Candida urinary tract infections (UTIs) is
discussed elsewhere. (See "Candida infections of the bladder and kidneys", section on
'Treatment'.)
Indications for hospitalization — The decision to admit patients with acute complicated UTI
should be individualized. The decision to admit is usually clear when patients are septic or
otherwise critically ill. Otherwise, general indications for inpatient management include
persistently high fever (eg, >38.4°C/>101°F) or pain, marked debility, or inability to maintain oral
hydration or take oral medications. Additionally, inpatient management is warranted when
urinary tract obstruction is suspected or there are concerns regarding patient adherence.
Outpatient management is acceptable for patients with acute complicated UTI of mild to
moderate severity who can be stabilized, if necessary, with rehydration and antimicrobials in an
outpatient facility or the emergency department and discharged on oral antimicrobials with
close follow-up.
Many patients can be managed in the outpatient setting. As an example, in a study of 44

patients with pyelonephritis but no major comorbidities, a 12-hour observation period with
parenteral antimicrobial therapy in the emergency department followed by completion of
outpatient oral antimicrobials was effective management for 97 percent of patients [27].
Empiric antimicrobial therapy — The approach to empiric therapy of acute complicated UTI

depends on the severity of illness, the risk factors for resistant pathogens, and specific host
factors [1]. The choice among the options presented for each population depends on
susceptibility of prior urinary isolates, patient circumstances (such as allergy or expected
tolerability, history of prior antimicrobial use), local community resistance prevalence of
Enterobacterales (if known), and drug toxicity, interactions, availability, and cost ( table 3 and
algorithm 1 and algorithm 2).
Urine culture and susceptibility testing should be performed in all patients, and the initial
empiric regimen should be tailored appropriately to the susceptibility profile of the infecting
pathogen, once known [1]. (See 'Directed antimicrobial therapy' below.)
Data evaluating the efficacy of various regimens for acute complicated UTI are limited, and only
a small number of different regimens have been formally evaluated [28,29]. The
recommendations in this section are based instead on the expected microbial spectrum of
antimicrobial agents that achieve adequate urinary tract and systemic levels.
Critical illness and/or urinary tract obstruction — We use a broad-spectrum antimicrobial

regimen for empiric therapy of patients with acute complicated UTI who are critically ill (ie, with
severe sepsis or otherwise warranting intensive care unit admission), getting worse on current
therapy, or who have suspected urinary tract obstruction (eg, if the renal function has declined
below baseline or if there is a decline in urine output) ( table 3 and algorithm 1).
In such patients, we suggest an antipseudomonal carbapenem (imipenem 500 mg

intravenously [IV] every six hours or meropenem 1 g IV every eight hours) to cover extended-
spectrum beta-lactamase (ESBL)-producing organisms and Pseudomonas aeruginosa, as well as
vancomycin to cover methicillin-resistant Staphylococcus aureus (MRSA). Daptomycin and
linezolid are alternatives to vancomycin.
The rationale for such broad coverage in these patients is the high risk of adverse outcomes
should empiric antimicrobial therapy be insufficient and the increasing prevalence of multidrug-
resistant organisms, even in the general population (see 'Microbiology' above). Patients who
have a UTI in the setting of urinary tract obstruction are at a particularly high risk of clinical
decompensation.
Ultimately, however, the selection of antimicrobial therapy should be individualized. In locations

where the community prevalence of multidrug-resistant organisms (in particular, ESBL-
producing organisms) is low, regimens with a narrower spectrum may be appropriate. In such
cases, regimen selection can be based on individual risk of resistance, as discussed elsewhere.
(See 'Other hospitalized patients' below.)
Advanced cephalosporin or carbapenem combinations with beta-lactamase inhibitors, the novel

cephalosporin cefiderocol, the advanced aminoglycoside plazomicin, and parenteral fosfomycin
also have activity against some ESBL-producing Enterobacterales and, in some cases,
multidrug-resistant P. aeruginosa isolates and are effective for acute complicated UTI [30-34];
however, because of cost and antimicrobial stewardship concerns, as well as limited data for
some of the agents, they should only be used in select cases of highly resistant infections. If
carbapenem resistance is suspected based on prior susceptibility testing results, an infectious
diseases consult should be obtained. (See "Overview of carbapenemase-producing gram-
negative bacilli", section on 'Treatment'.)
Patients with critical illness or obstruction also warrant imaging to evaluate for obstruction or
other complications that may warrant intervention. (See 'Imaging' above.)
Results of urine culture and susceptibility testing should be followed to ensure that the chosen
empiric antimicrobial regimen is appropriate and to guide selection of definitive therapy. If
feasible, antibiotics with a narrow spectrum of activity should be chosen to complete the
antibiotic course. (See 'Directed antimicrobial therapy' below.)
Other hospitalized patients — For patients who are hospitalized for acute complicated UTI
(see 'Indications for hospitalization' above) but are not critically ill and do not have suspected
urinary tract obstruction, our approach to empiric antimicrobial regimen selection depends on
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the risk for infection with multidrug-resistant gram-negative organisms ( table 3 and
algorithm 1).
● No risk factors for infection with a multidrug-resistant gram-negative organism

( table 2) – For these patients, we favor ceftriaxone (1 g IV once daily) or piperacillin-
tazobactam (3.375 g IV every six hours) for parenteral treatment because of their safety
profile and narrow spectrum compared with other parenteral agents. Oral or parenteral
fluoroquinolones (ciprofloxacin or levofloxacin) are also reasonable alternatives if the
patient has not had a urinary isolate resistant to fluoroquinolones in the prior three
months and the community prevalence of E. coli fluoroquinolone resistance is not known
to be higher than 10 percent.
Concern for particular pathogens should further inform the choice between these options.
If Enterococcus or Staphylococcus species are suspected (eg, because of prior urinary
isolates), piperacillin-tazobactam is preferred because it has activity against these
organisms (if the patient cannot use piperacillin-tazobactam because of allergies or
otherwise, vancomycin plus one of the other gram-negative agents can be used). If drug-
resistant gram-positive organisms are suspected because of previous urinary isolates or
other risk factors, vancomycin (for MRSA) or linezolid or daptomycin (for vancomycin-
resistant Enterococcus [VRE]) should be added. If there is a risk of P. aeruginosa (eg,
because of prior urinary isolates or febrile neutropenia), piperacillin-tazobactam or a
fluoroquinolone should be chosen.
● At least one risk factor for infection with a multidrug-resistant gram-negative

organism ( table 2) – For these patients, we favor empiric treatment with piperacillin-
tazobactam 3.375 g IV every six hours, cefepime 2 g IV every 12 hours, or an
antipseudomonal carbapenem (imipenem 500 mg IV every six hours or meropenem 1 g IV
every eight hours).
Concern for particular pathogens should further inform regimen selection. If patients
have risk factors for an ESBL-producing organism, we avoid cefepime, and for those with
recent (eg, within the prior three months) history of infection with ESBL-producing
organisms, we specifically choose a carbapenem. If resistant Enterococcus species or MRSA
are suspected (eg, because of prior urinary isolates), we add vancomycin (for MRSA) or
daptomycin or linezolid (for vancomycin-resistant Enterococcus [VRE]). All the listed options
have activity against P. aeruginosa; ceftazidime (2 g IV every eight hours) is another
antipseudomonal agent.
If available (not in the United States), parenteral fosfomycin is also effective for
complicated UTI and has activity against certain MDR organisms, such as ESBL-producing
organisms [34]; we would reserve this agent as an alternative to carbapenems as more
widespread use could promote resistance, decreasing the utility of oral fosfomycin.
Additionally, it may not be tolerated as well as other agents [35].
Advanced cephalosporin or carbapenem combinations with beta-lactamase inhibitors and

the novel cephalosporin cefiderocol also have activity against some ESBL-producing
Enterobacterales and, in some cases, multidrug-resistant P. aeruginosa isolates and are
effective for acute complicated UTI [30-33]; however, because of cost and antimicrobial
stewardship concerns, they should only be used in select cases of highly resistant
infections. If carbapenem resistance is suspected based on prior susceptibility testing
results, an infectious diseases consult should be obtained. (See "Overview of
carbapenemase-producing gram-negative bacilli", section on 'Treatment'.)
empiric antimicrobial regimen is appropriate and to guide selection of definitive therapy. If
feasible, antibiotics with a narrow spectrum of activity should be chosen to complete the
antibiotic course. (See 'Directed antimicrobial therapy' below.)
Outpatients — Patients with acute complicated UTI of mild to moderate severity who can take
oral medications reliably can be treated in the outpatient setting. The approach to selection of
an empiric outpatient antimicrobial regimen depends on the risk factors for infection with a
multidrug-resistant organism (in particular ESBL-producing isolates) ( table 3 and
algorithm 2). Recommended regimens are outlined below. (See 'Low risk of MDR infection'
below and 'High risk of MDR infection' below.)
Whether fluoroquinolones can be used (accounting for contraindications or concerns for

fluoroquinolone resistance specifically) is also an important consideration in regimen selection.
In the absence of resistance, fluoroquinolones provide a broad spectrum of antimicrobial
activity against most uropathogens (including P. aeruginosa) and achieve high levels in the
urinary tract. Studies of acute complicated UTI have shown that the fluoroquinolones are
generally comparable or superior to other broad-spectrum antimicrobials, including parenteral
regimens [28,36]. However, increasing rates of resistance to fluoroquinolones among
uropathogens, even among outpatients, are diminishing their value for this purpose [37]. (See
"Acute simple cystitis in women", section on 'Resistance trends in E. coli'.)
When a fluoroquinolone can be used, ciprofloxacin or levofloxacin are the most common
agents. Other less commonly used fluoroquinolones that are effective for UTIs include ofloxacin
and norfloxacin. Moxifloxacin attains lower urinary levels than other fluoroquinolones and
should not be used.
Although there are concerns about the potential adverse effects, including Clostridioides difficile
infection and ecological effects (ie, selection of resistant organisms) caused by the
fluoroquinolones, their benefits are thought to outweigh their risks for acute complicated UTI.
Low risk of MDR infection — For outpatients with acute complicated UTI and no risk
factors for infection with a multidrug-resistant (MDR) gram-negative organism ( table 2),
empiric antimicrobial regimen selection depends on contraindications to or other concerns with
fluoroquinolones ( table 3 and algorithm 2). These include allergy or intolerance to the
fluoroquinolone class (including prolonged QT interval or other risk factors for torsades de
pointes) or an unmodifiable drug interaction. Because of the prevalence of fluoroquinolone
resistance and underlying comorbidities associated with adverse effects, fluoroquinolone-
sparing regimens are often an appropriate option.
● Fluoroquinolone-based regimens – For patients who have no contraindications to

fluoroquinolones and are at low personal risk for a fluoroquinolone-resistant isolate
( table 2), we suggest an oral fluoroquinolone for empiric therapy. Appropriate regimens
include ciprofloxacin 500 mg twice daily, ciprofloxacin 1000 mg extended release once
daily, or levofloxacin 750 mg once daily [38-42]. Fluoroquinolones are given for five to
seven days.
In the case that community prevalence of E. coli fluoroquinolone resistance is known to be

higher than 10 percent, we suggest a single dose of a long-acting parenteral agent prior
to administering the fluoroquinolone [43]. We prefer ceftriaxone (1 g IV or intramuscular
[IM] once) because of its safety, efficacy, and microbial spectrum. Ertapenem (1 g IV or IM
once) is an alternative for patients with an allergy that precludes ceftriaxone use or
expected resistance to ceftriaxone, and aminoglycosides (gentamicin or tobramycin 5 mg
per kg IV or IM once) are reserved for patients who cannot use the other two. Since timely
use of an agent with in vitro activity is essential to treat acute complicated UTI and
minimize progression of infection, the threshold for selecting an antimicrobial for empiric
broad-spectrum therapy should be set at a relatively low resistance prevalence. For
fluoroquinolones, a resistance prevalence of 10 percent has been suggested based on
expert opinion [1].
The benefits of fluoroquinolones are thought to outweigh their risks for acute complicated
UTI, but patients should be advised about the uncommon but potentially serious
musculoskeletal and neurologic adverse effects associated with fluoroquinolones. (See

"Fluoroquinolones", section on 'Adverse effects'.)
● Fluoroquinolone-sparing regimens – For patients who have contraindications to

fluoroquinolones or other concerns about fluoroquinolone use, our approach depends on
the relative severity of illness. For those with mild infection, we use a single dose of a long-
acting parenteral agent followed by a non-fluoroquinolone oral agent [43].
As above, we prefer ceftriaxone (1 g IV or IM once) as a long-acting parenteral agent

because of its safety, efficacy, and microbial spectrum. Ertapenem (1 g IV or IM once) is an
alternative for patients with an allergy that precludes ceftriaxone use or expected
resistance to ceftriaxone, and aminoglycosides (gentamicin or tobramycin 5 mg per kg IV
or IM once) are reserved for patients who cannot use the other two.
Following the dose of the parenteral agent, options include the following:
• Trimethoprim-sulfamethoxazole – one double-strength (160 mg/800 mg) tablet orally

twice daily for 7 to 10 days
• Amoxicillin-clavulanate – 875 mg orally twice daily for 7 to 10 days
• Cefpodoxime – 200 mg orally twice daily for 7 to 10 days
• Cefdinir – 300 mg orally twice daily for 7 to 10 days
• Cefadroxil – 1 g orally twice daily for 7 to 10 days
For outpatients who are systemically ill or are at risk for more severe illness, we favor
continuing the parenteral therapy until culture and susceptibility testing results can guide
selection of an appropriate oral agent.
empiric antimicrobial regimen is appropriate and to guide modification of the regimen, if
necessary. The durations of therapy listed above assume that the patient is appropriately
responding to antibiotic therapy; longer durations or re-evaluation may be warranted in those
who are slow to respond. These issues are discussed in detail elsewhere. (See 'Directed
antimicrobial therapy' below.)
In some cases, results of urine culture and susceptibility testing may be known at the time of
treatment initiation. For those with mild illness caused by a susceptible pathogen, oral therapy
with trimethoprim-sulfamethoxazole without initial parenteral therapy is reasonable. If
trimethoprim-sulfamethoxazole is not an option, an oral beta-lactam is an alternative (if the
organism is susceptible), but based on data from cystitis studies, it is generally associated with
lower efficacy rates for UTI.
High risk of MDR infection — For outpatients with acute complicated UTI and risk factors
for infection with a multidrug-resistant (MDR) gram-negative organism ( table 2), we suggest
giving an initial dose of ertapenem 1 g IV or IM ( table 3 and algorithm 2). Plazomicin is a
potential alternative in this setting; clinical experience with this agent is limited.
For patients who have no contraindications to fluoroquinolones (ie, allergy or expected

intolerability, including risk factors for torsades de pointes, or unmodifiable drug interaction)
and have not had fluoroquinolone use or a fluoroquinolone-resistant urinary isolate in the prior
three months, we follow this dose of ertapenem with a fluoroquinolone. Appropriate regimens
include ciprofloxacin 500 mg twice daily, ciprofloxacin 1000 mg extended release once daily,
and levofloxacin 750 mg once daily [38-42]. Fluoroquinolones are given for five to seven days.
The benefits of fluoroquinolones for acute complicated UTI are thought to outweigh their risks,
but patients should be advised about the uncommon but potentially serious musculoskeletal
and neurologic adverse effects associated with fluoroquinolones. (See "Fluoroquinolones",
section on 'Adverse effects'.)
For patients who have either contraindications or concern for fluoroquinolone resistance, we
instead continue to administer ertapenem 1 g IV or IM daily in the outpatient setting until
culture and susceptibility testing results return. As above, once-daily plazomicin is a potential
alternative; dosing and toxicity monitoring are discussed elsewhere. (See "Dosing and
administration of parenteral aminoglycosides", section on 'Plazomicin'.)
Once available, culture and susceptibility testing results should guide selection of definitive
therapy. (See 'Directed antimicrobial therapy' below.)
Directed antimicrobial therapy
Regimen selection — Results of urine culture and susceptibility testing should be used to

tailor the regimen, if appropriate. In many cases, broad-spectrum empiric regimens can be
replaced by a more narrow-spectrum agent. Patients who were initially treated with a
parenteral regimen can be switched to an oral agent once symptoms have improved, as long as
culture and susceptibility testing allow. Options depend on the pathogen identified:
● Enterobacterales (eg, E. coli, K. pneumoniae, P. mirabilis):
• Susceptible isolates – For susceptible Enterobacterales, appropriate oral agents to treat

acute complicated UTI include levofloxacin (750 mg once daily), ciprofloxacin (500 mg
twice daily or 1000 extended release once daily), and trimethoprim-sulfamethoxazole
(one double-strength [160 mg/800 mg] tablet orally twice daily) [38-40]. Oral beta-
lactams may be less effective for acute complicated UTI (based on cystitis studies) but
are appropriate alternatives if susceptibility is documented and the other agents are
not feasible.
• Resistant isolates – Some isolates that are resistant to beta-lactams (eg, ESBL-
producing Enterobacterales) may still be susceptible to fluoroquinolones and
trimethoprim-sulfamethoxazole, in which case those agents can be used orally as
above. However, for Enterobacterales that are resistant to fluoroquinolones,
trimethoprim-sulfamethoxazole, and oral beta-lactams, a parenteral agent is generally
needed to complete the course of treatment. We use the most narrow-spectrum agent
that has expected activity. For ESBL-producing bacteria, this is usually a carbapenem
(meropenem, imipenem, or ertapenem). The drawbacks to using piperacillin-
tazobactam or cefepime for ESBL-producing bacteria are discussed elsewhere.
Treatment of carbapenem-resistant gram-negative bacteria is also discussed
elsewhere. (See "Extended-spectrum beta-lactamases", section on 'Treatment options'
and "Overview of carbapenemase-producing gram-negative bacilli", section on
'Therapy for carbapenemase-producing Enterobacterales'.)
Options for outpatient administration of parenteral antimicrobials include use of a

peripherally inserted central catheter, a pre-existing central catheter, or IM injection.
Nitrofurantoin, oral fosfomycin, and pivmecillinam should generally be avoided in the

setting of acute complicated UTI because they do not achieve adequate tissue levels
outside the bladder [1].
Novel options for outpatient management of resistant gram-negative bacteria are

needed. In a randomized trial that included 868 adults hospitalized for complicated
UTI, an experimental oral carbapenem, tebipenem, resulted in similar clinical cure rates
as intravenous ertapenem, each given for 7 to 10 days (93 versus 94 percent at day 19)
[44]. Microbiologic cure rates were lower with tebipenem for ESBL-producing
organisms, but clinical response with these pathogens remained high. While a
promising agent, the risk of selecting for carbapenem resistance is a concern and
judicious use, if available in the future, will be important.
● Enterococcus – If Enterococcus is isolated, amoxicillin (500 mg orally every eight hours or

875 mg twice daily) is the agent of choice if the organism is susceptible; other UpToDate
contributors favor a higher dose of amoxicillin in this setting [45,46]. (See "Treatment of
enterococcal infections", section on 'Urinary tract infection'.)
● Pseudomonas – Directed therapy of Pseudomonas UTI is discussed in detail elsewhere. (See

"Pseudomonas aeruginosa infections of the eye, ear, urinary tract, gastrointestinal tract,
and central nervous system", section on 'Treatment'.)
● Staphylococcus – Oral options include trimethoprim-sulfamethoxazole (one double-

strength [160 mg/800 mg] tablet orally twice daily) or, for methicillin-susceptible
Staphylococcus species, cefadroxil (500 mg twice daily). S. aureus is a relatively uncommon
urinary isolate. When S. aureus is isolated from the urine in a patient with complicated UTI,
blood cultures are warranted to rule out bacteremia. The urinary tract can be the original
source of S. aureus bacteremia or a secondary site seeded from hematogenous spread.
The reported rate of concurrent or subsequent bacteremia in patients with S. aureus
bacteriuria varies between approximately 5 and 20 percent [47-49]. (See "Clinical
manifestations of Staphylococcus aureus infection in adults", section on 'Bacteriuria'.)
Duration — Total duration of antimicrobial therapy generally ranges from 5 to 10 days,

depending on the rapidity of clinical response and the antimicrobial chosen to complete the
course. For individuals who have an appropriate clinical response (symptomatic improvement
within the first 48 to 72 hours of therapy), we give fluoroquinolones for 5 to 7 days,
trimethoprim-sulfamethoxazole for 7 to 10 days [50], and beta-lactams for 7 to 10 days. For
those who have slow response to appropriate antibiotic therapy (eg, no symptomatic
improvement within the first 48 to 72 hours of therapy), evaluation should assess for infectious
complications or for underlying anatomic abnormalities that could delay response (see
'Imaging' above). Longer antibiotic durations may be warranted in patients who have a nidus of
infection (such as a nonobstructing stone) that cannot be removed. The duration of
antimicrobial therapy need not be extended in the setting of bacteremia when other
complicating factors are absent; there is no evidence that bacteremia portends a worse
prognosis [51]. A potential exception is S. aureus bacteremia, which is discussed in detail
elsewhere. (See "Clinical approach to Staphylococcus aureus bacteremia in adults", section on
'Clinical approach'.)
Several systematic reviews and meta-analyses of randomized trials have suggested that shorter
antibiotic courses (seven days or fewer) for complicated UTI result in similar clinical cure rates
compared with longer courses [52-54]. Most of these data come from randomized trials of
fluoroquinolones, in which five- or seven-day regimens of fluoroquinolones were comparable to
longer durations [39,41,55]. Data are more limited for other antibiotic classes, and studies
evaluating beta-lactams included older agents that are not commonly used for UTI.
Nevertheless, those studies failed to identify a clear clinical benefit to treating longer than
seven days [53].
Addressing underlying urinary tract abnormalities — In addition to antimicrobial therapy,

the possibility of urinary obstruction should be considered and managed, if identified. Patients
who have underlying anatomical or functional urinary tract abnormalities (including neurogenic
bladder, indwelling bladder catheters, nephrostomy tubes, urethral stents) may warrant
additional management, such as more frequent catheterization to improve urinary flow,
exchange or removal of a catheter, and/or urologic or gynecologic consultation. Antimicrobials
alone may not be successful unless such underlying conditions are corrected [56]. (See
"Catheter-associated urinary tract infection in adults", section on 'Catheter management'.)
Follow-up — Symptoms should improve promptly if antimicrobial therapy is effective. Among

patients treated as outpatients, those who had pyelonephritis should have close follow-up
either face-to-face or by telephone within 48 to 72 hours.
Any patients who have worsening symptoms following initiation of antimicrobials, persistent
symptoms after 48 to 72 hours of appropriate antimicrobial therapy, or recurrent symptoms
within a few weeks of treatment should have additional evaluation, including abdominal/pelvic
imaging (generally with computed tomography if not already performed) for factors that might
be compromising clinical response. Urine culture and susceptibility testing should be repeated,
and treatment should be tailored to the susceptibility profile of other causative organisms
isolated.
For patients who had hematuria on initial presentation, a urinalysis should be repeated several
weeks following antimicrobial therapy to evaluate for persistent hematuria. (See "Etiology and
evaluation of hematuria in adults", section on 'Overall approach to the evaluation'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Urinary tract infections
in adults".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Beyond the Basics topics (see "Patient education: Urinary tract infections in adolescents
and adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Terminology – We use the term acute complicated urinary tract infection (UTI) to refer to
an acute UTI with any features that suggest that the infection extends beyond the bladder
( table 1). These include fever (eg, >99.9°F/37.7°C), other signs or symptoms of systemic
illness (including chills, rigors, or altered mental status), flank pain, and costovertebral
angle tenderness. By this definition, pyelonephritis is a complicated UTI, regardless of
patient characteristics. This definition is distinct from traditional categorizations of UTI and
is more focused on the clinical presentation and severity of illness. (See 'Terminology'
above.)
● Microbiology – Relevant uropathogens include primarily Escherichia coli, but also other
Enterobacterales, other gram-negative bacilli (including Pseudomonas aeruginosa),
staphylococci, enterococci, and Candida species. Risk factors for resistant organisms
include recent broad-spectrum antimicrobial use, health care exposures, and travel to
parts of the world where multidrug-resistant organisms are prevalent ( table 2). (See
'Microbiology' above.)
● Clinical suspicion – Acute complicated UTI should be suspected in patients with dysuria,
urinary frequency or urgency, or suprapubic pain who also have fever, chills, flank pain, or
otherwise appear clinically ill. Acute pyelonephritis, specifically, should be suspected in
patients presenting with fever and flank pain, even in the absence of typical symptoms of
cystitis. In men, pelvic or perineal pain accompanying urinary symptoms suggests
prostatitis. UTI is also often suspected in patients with pyuria and bacteriuria who have
nonspecific signs of systemic illness, such as lethargy or delirium, or in patients with
nonlocalizing fever or sepsis. (See 'Clinical manifestations' above and 'Evaluation' above.)
● Evaluation – For patients with suspected acute complicated UTI, we send urine for both
urinalysis (either by microscopy or by dipstick) and culture with susceptibility testing.
Imaging is generally reserved for those who are severely ill, have suspected urinary tract
obstruction, have persistent symptoms despite 48 to 72 hours of appropriate
antimicrobial therapy, or have recurrent symptoms. (See 'Evaluation' above and 'Imaging'
above.)
● Diagnosis – The diagnosis of acute complicated UTI is made in patients who have
consistent clinical findings as well as pyuria and bacteriuria. UTI is unlikely if pyuria is
absent. (See 'Diagnosis' above.)
● Indications for hospitalization – Outpatient management is acceptable for patients with

acute complicated UTI of mild to moderate severity who can be stabilized, if necessary,
with rehydration and antimicrobials in an outpatient facility or the emergency department
and discharged on oral antimicrobials with close follow-up. (See 'Indications for
hospitalization' above.)
● Empiric therapy – The approach to empiric therapy of acute complicated UTI depends on
the severity of illness, the risk factors for resistant pathogens, and specific host factors
( table 3 and algorithm 1 and algorithm 2). (See 'Empiric antimicrobial therapy'
above.)
• Critical illness/urinary tract obstruction – For patients who are critically ill or have
urinary tract obstruction, we suggest an antipseudomonal carbapenem (meropenem
or imipenem) plus vancomycin (Grade 2C). (See 'Critical illness and/or urinary tract
obstruction' above.)
• Other hospitalized patients – For hospitalized patients without critical illness or

urinary tract obstruction who have no risk factors for a multidrug-resistant (MDR)
gram-negative infection ( table 2), we suggest ceftriaxone or piperacillin-tazobactam
(Grade 2C). Oral or parenteral fluoroquinolones are also reasonable options. For
patients who have risk factors for an MDR gram-negative infection, we suggest
piperacillin-tazobactam, cefepime, or an antipseudomonal carbapenem (Grade 2C). For
those with a recent history of an ESBL-producing urinary isolate specifically, we use a
carbapenem. (See 'Other hospitalized patients' above.)
• Outpatients without risk for resistance – For outpatients without risk factors for an
MDR gram-negative infection ( table 2), we suggest an oral fluoroquinolone, such as
levofloxacin or ciprofloxacin (Grade 2B). If the community prevalence of E. coli
fluoroquinolone resistance is known to be higher than 10 percent, we also suggest a
single dose of a long-acting parenteral agent such as ceftriaxone or ertapenem prior to
administering the fluoroquinolone (Grade 2C). (See 'Low risk of MDR infection' above.)
• Outpatients with risk for resistance – For outpatients with risk factors for an MDR
gram-negative infection ( table 2), we suggest an initial dose of ertapenem (Grade
2C). Subsequently, an oral fluoroquinolone or daily ertapenem can be used. (See 'High
risk of MDR infection' above.)
● Directed therapy and duration – Results of urine culture and susceptibility testing should
be used to confirm that the chosen empiric regimen is active and to tailor the regimen,
including switching a parenteral regimen to an oral agent once symptoms have improved.
Appropriate oral agents to treat acute complicated UTI include fluoroquinolones (eg,
levofloxacin or ciprofloxacin, given for 5 to 7 days) or trimethoprim-sulfamethoxazole
(given for 7 to 10 days). Oral beta-lactams (given for 7 to 10 days) are less effective for
acute complicated UTI but are appropriate alternatives if susceptibility is documented and
the other agents are not feasible. (See 'Directed antimicrobial therapy' above.)
● Urologic issues – Patients who have underlying anatomical or functional urinary tract
abnormalities (including neurogenic bladder, indwelling bladder catheters, nephrostomy
tubes, urethral stents) may warrant additional management, such as more frequent
catheterization to improve urinary flow, exchange or removal of a catheter, and/or
urologic or gynecologic consultation. (See 'Addressing underlying urinary tract
abnormalities' above.)
Use of UpToDate is subject to the Terms of Use.
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53. Erba L, Furlan L, Monti A, et al. Short vs long-course antibiotic therapy in pyelonephritis: a
comparison of systematic reviews and guidelines for the SIMI choosing wisely campaign.
Intern Emerg Med 2021; 16:313.
54. Hanretty AM, Gallagher JC. Shortened Courses of Antibiotics for Bacterial Infections: A
Systematic Review of Randomized Controlled Trials. Pharmacotherapy 2018; 38:674.
55. van Nieuwkoop C, van der Starre WE, Stalenhoef JE, et al. Treatment duration of febrile
urinary tract infection: a pragmatic randomized, double-blind, placebo-controlled non-
inferiority trial in men and women. BMC Med 2017; 15:70.

56. Nicolle LE. A practical guide to the management of complicated urinary tract infection.
Drugs 1997; 53:583.
Topic 16109 Version 61.0
GRAPHICS
Our approach to categorizing UTI in adults and adolescents
Acute simple cystitis* Acute UTI that is presumed to be confined to the bladder
There are no signs or symptoms that suggest an upper tract or
systemic infection (refer to below)
Acute complicated UTI Acute UTI accompanied by signs or symptoms that suggest
extension of infection beyond the bladder:
Fever (>99.9°F/37.7°C)¶
Chills, rigors, significant fatigue or malaise beyond baseline, or
other features of systemic illness
Flank pain
Costovertebral angle tenderness
Pelvic or perineal pain in men
Special populations with Pregnant women

unique management Renal transplant recipients
considerations
We categorize UTI as either acute simple cystitis or acute complicated UTI based on the extent and
severity of infection. This categorization informs management and differs somewhat from other
conventions. Specifically, cystitis or pyelonephritis in a nonpregnant premenopausal woman without
underlying urologic abnormalities has traditionally been termed acute uncomplicated UTI, and
complicated UTI has been defined, for the purposes of treatment trials, as cystitis or pyelonephritis
in a patient with underlying urologic abnormalities or other significant comorbidities. Individuals
who do not fit into either category have often been treated as having a complicated UTI by default.
Rather than use this convention, we favor an approach to treatment based on the presumed extent
of infection and severity of illness. Patients categorized as having acute uncomplicated cystitis
according to traditional definitions would fall under the category of acute simple cystitis that we use
here.
UTI: urinary tract infection.
* We do not automatically consider patients with underlying urologic abnormalities (such as

nephrolithiasis, strictures, stents, or urinary diversions), immunocompromising conditions (such as
neutropenia or advanced HIV infection), or poorly controlled diabetes mellitus to have a complicated
UTI if they have no concerning symptoms for upper tract or systemic infection. However, such
patients can be at higher risk for more serious infection and have not traditionally been included in
studies evaluating the antibiotic regimens we typically use for acute simple cystitis. Thus, we follow
such patients more closely and/or have a low threshold to manage them as complicated UTI (eg, if
they have subtle symptoms other than those listed above that could be suggestive of more
extensive infection).
¶ This temperature threshold is not well defined and should be individualized, taking into account
baseline temperature, other potential contributors to an elevated temperature, and the risk of poor
outcomes should empiric antimicrobial therapy be inappropriate.
Graphic 117508 Version 2.0
Risk factors for multidrug-resistant gram-negative urinary tract infections
Suspect multidrug-resistant gram-negative urinary tract infection in patients with

a history of any of the following in the prior three months:
A multidrug-resistant gram-negative urinary isolate or a fluoroquinolone-resistant

Pseudomonas aeruginosa isolate
Inpatient stay at a health care facility (eg, hospital, nursing home, long-term acute care facility)
Use of a fluoroquinolone, trimethoprim-sulfamethoxazole, or broad-spectrum beta-lactam (eg,

third or later generation cephalosporin)*
Travel to parts of the world with high rates of multidrug-resistant organisms¶
NOTE: The predictive value of these risk factors for multidrug-resistant gram-negative urinary tract
infections has not been systematically evaluated. In particular, the time interval since these exposures
is not well validated. The threshold for empirically covering a multidrug-resistant infection varies with
the severity of infection, with a lower threshold warranted for more severe disease.
Multidrug resistance refers to nonsusceptibility to at least one agent in three or more antibiotic
classes. This includes isolates that produce an extended-spectrum beta-lactamase (ESBL).
* This includes a single antibiotic dose given for prophylaxis prior to prostate procedures.
¶ The prevalence of multidrug resistance is not well documented in all parts of the world. Some
countries where the prevalence is particularly high include India, Israel, Spain, and Mexico.
Ultrasonography of acute pyelonephritis
Renal ultrasonography in a patient with acute pyelonephritis

showing a hypodense mass with internal echoes (outlined by the
arrows).
Courtesy of Alain Meyrier, MD.
Computed tomography scan of acute

pyelonephritis
Contrast-enhanced CT scan in a patient with acute pyelonephritis

showing a large, hypodense region in the right kidney. There is no
discrete abscess formation in this setting.
Computed tomography scan of bilateral acute

pyelonephritis
Contrast-enhanced CT scan in bilateral acute pyelonephritis showing

triangular hypodense streaks spreading from the pelvis to the renal
cortex (arrows).
Empiric antimicrobial agent selection for acute complicated urinary tract

infection
Patient Risk for MDR?

Empiric regimens Comments
population *
Hospitalized with: N/A An antipseudomonal The rationale for broad

Critical carbapenem: coverage is the high risk
illness Imipenem 500 mg IV of adverse outcomes
warranting every 6 hours infused with insufficient
intensive over 3 hours or antimicrobial therapy.
care (eg, Meropenem 1 g IV In regions with low
severe every 8 hours infused community prevalence of
sepsis) or over 3 hours ESBL-producing
Urinary organisms, it is
PLUS
tract reasonable to select a
obstruction Vancomycin 15 to 20 regimen based on
mg/kg IV every 8 to 12 individual MDR risk, as
hours with or without a listed for "Other
loading dose hospitalized patients."
Other No Ceftriaxone 1 g IV once If Enterococcus or

hospitalized daily or Staphylococcus species
patients Piperacillin-tazobactam are suspected (eg, based
3.375 g IV every 6 hours on prior isolates),
or piperacillin-tazobactam
Alternatives: is preferred.
Levofloxacin 750 mg If Pseudomonas is

IV or orally daily suspected (based on
prior isolates),
Ciprofloxacin 400 mg
piperacillin-tazobactam
IV twice daily
or a fluoroquinolone is
Ciprofloxacin 500 mg
preferred.
orally twice daily
Ciprofloxacin
extended-release
1000 mg orally once
daily
Yes Piperacillin-tazobactam If VRE or MRSA are

3.375 g IV every 6 hours suspected (eg, based on
or prior isolates),
Cefepime 2 g IV every 12 vancomycin (for MRSA)
hours (not for ESBL risk) or daptomycin or
or linezolid (for VRE) is
added.
An antipseudomonal
carbapenem (if recent
ESBL isolate):
Imipenem 500 mg IV
every 6 hours infused
over 3 hours or
Meropenem 1 g IV
every 8 hours infused
over 3 hours
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 for Ciprofloxacin 500 mg resistance in Escherichia
adverse effects) orally twice daily for 5 coli is known to be >10%,
to 7 days or give one dose of a long-
Ciprofloxacin acting parenteral agent
extended-release prior to the
1000 mg orally once fluoroquinolone:
daily for 5 to 7 days Ceftriaxone 1 g IV or
or IM once
Levofloxacin 750 mg Ertapenem 1 g IV or
orally once daily for 5 IM once
to 7 days 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 who are
concerns with use a fluoroquinolone: systemically ill or are at
fluoroquinolones One dose of a long- risk for more severe
(eg, at risk for acting parenteral illness, we favor
adverse effects) agent: continuing the
Ceftriaxone 1 g IV parenteral agent until
or IM once or culture and susceptibility
testing results can guide
Ertapenem 1 g IV
selection of an
or IM once or
appropriate oral agent.
Gentamicin 5
mg/kg IV or IM
once or
Tobramycin 5
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 7 to 10
days or
Cefpodoxime 200
mg orally twice
daily for 7 to 10
days or
Cefdinir 300 mg
orally twice daily
for 7 to 10 days
or
Cefadroxil 1 g
orally twice daily
for 7 to 10 days
Yes Ertapenem 1g IV or IM If the patient cannot take

once a fluoroquinolone or has
Followed by: high risk for
Ciprofloxacin 500 mg fluoroquinolone
orally twice daily for 5 resistance
to 7 days or (fluoroquinolone-
resistant isolate or
Ciprofloxacin
fluoroquinolone use in
extended-release
prior three months):
1000 mg orally once
daily for 5 to 7 days Ertapenem 1 g IV or
or IM once daily until
cultures and
Levofloxacin 750 mg
susceptibility testing
orally daily for 5 to 7
return
days
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, including a fluoroquinolone-resistant Pseudomonas
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
Empiric antimicrobial selection for acute complicated urinary tract infection in
This algorithm reflects our approach to the selection of empiric antimicrobial therapy for patients hospit
an acute complicated UTI. Ultimately, the selection of antimicrobial therapy should be individualized bas
community risk factors for resistant pathogens, and specific host factors.
The decision to hospitalize a patient is usually clear in the setting of critical illness or sepsis. Otherwise, g
management include persistently high fever (eg, >101°F/>38.4°C) or pain, marked debility, inability to ma
medications, suspected urinary tract obstruction, and concerns regarding adherence to therapy. If outpa
therapy in the emergency department, refer to other UpToDate content on antimicrobial therapy selectio
In addition to antimicrobial therapy, the possibility of urinary obstruction should be considered and man
anatomical or functional urinary tract abnormalities (including neurogenic bladder, indwelling bladder ca
stents) may warrant additional management, such as more frequent catheterization to improve urinary f
urologic or gynecologic consultation.
Doses listed are for patients with normal renal function and may require adjustment in the setting of ren
UTI: urinary tract infection; MDR: multi-drug resistant; FQ: fluoroquinolone; ESBL: extended-spectrum beta-l
sulfamethoxazole; IV: intravenous; PO: oral; MRSA: methicillin-resistant Staphylococcus aureus; VRE: vancomy
* We consider individuals who have pyuria with only cystitis symptoms to have acute simple cystitis and ma
symptoms suggest that infection has extended beyond the bladder and is a complicated UTI. The possibility
males with urinary and systemic symptoms. The temperature threshold used to determine whether to treat
complicated UTI is not well defined and should take into account baseline temperature, other potential cont
the risk of poor outcomes should empiric antimicrobial therapy be inappropriate.
¶ Features that should raise suspicion for urinary tract obstruction include a decline in the renal function be
colicky abdominal pain suggestive of nephrolithiasis.
Δ This includes a single antimicrobial dose given for prophylaxis prior to prostate procedures.
◊ Advanced cephalosporin or carbapenem combinations with beta-lactamase inhibitors and the advanced a
activity against some ESBL-producing and, in some cases, MDR Pseudomonas aeruginosa isolates and are eff
these should only be used in select cases of highly resistant infections. If carbapenem resistance is suspecte
results, an infectious diseases consult should be obtained.
§ The choice among these agents depends on susceptibility of prior urinary isolates, patient circumstances (
recent antimicrobial use), local community resistance prevalence (if known), drug toxicity and interactions, a
positive organisms are suspected because of previous urinary isolates or other risk factors, vancomycin (for
should be added.
¥ A longer duration of therapy may be warranted in patients who have a nidus of infection that cannot be re
symptoms following initiation of antimicrobials, persistent symptoms after 48 to 72 hours of appropriate an
within a few weeks of treatment should have additional evaluation including abdominal/pelvic imaging, if no
be compromising clinical response.
Empiric antimicrobial selection for acute complicated urinary tract infection in
This algorithm reflects our approach to the selection of empiric antimicrobial therapy for patients in the
antimicrobial therapy should be individualized based on severity of illness, individual and community risk
Outpatient management is acceptable for patients with mild to moderate illness, including those who ca
emergency room setting and discharged on oral antibiotics with close follow-up. Indications for inpatien
oral hydration or take oral medications, suspected urinary tract obstruction, and concerns regarding adh
content on antimicrobial therapy selection for the inpatient setting.
In addition to antimicrobial therapy, patients who have anatomical or functional urinary tract abnormalit
urethral stents) may warrant additional management, such as more frequent catheterization to improve
Doses listed are for patients with normal renal function and may require adjustment in the setting of ren
UTI: urinary tract infection;

MDR: multidrug-resistant;
ESBL: extended-spectrum beta-lactamase;
TMP-SMX: t
* We consider individuals who have pyuria with only cystitis symptoms to have acute simple cystitis and ma
beyond the bladder and is a complicated UTI. The possibility of prostatitis should also be considered in male
whether to treat a patient as simple cystitis or complicated UTI is not well defined and should take into acco
the risk of poor outcomes should empiric antimicrobial therapy be inappropriate.
¶ This includes a single antimicrobial dose given for prophylaxis prior to prostate procedures.
Δ Appropriate oral agents to treat complicated UTI include levofloxacin (5 to 7 days), ciprofloxacin (for 5 to 7
susceptibility is documented and other agents are not feasible.
◊ A longer duration of therapy may be warranted in patients who have a nidus of infection that cannot be r
persistent symptoms after 48 to 72 hours of appropriate antimicrobial therapy, or recurrent symptoms with
imaging, if not already performed) for factors that might be compromising clinical response.
§ Patients should be advised about the uncommon but potentially serious musculoskeletal and neurologic a
¥ Of the options listed, ceftriaxone is typically the preferred agent. Ertapenem is an alternative for patients w
patients who cannot use either.
‡ For outpatients who are more ill or are at risk for more severe illness, continuing the parenteral therapy pe
Contributor Disclosures
Kalpana Gupta, MD, MPH Equity Ownership/Stock Options: Abbot[Antibacterials that could be used for
UTI];First Light Diagnostics [Rapid detection and antimicrobial testing of infections];Pfizer[Antibacterials
that could be used for UTI].
Grant/Research/Clinical Trial Support: Pfizer [Staphylococcus aureus post-
surgical infections].
Consultant/Advisory Boards: Glaxo-Smith Kline [UTI];Qiagen [UTI];Spero Therapeutics
[UTI];Utility Therapeutics [UTI].
All of the relevant financial relationships listed have been
mitigated. Stephen B Calderwood, MD Consultant/Advisory Boards: Day Zero Diagnostics [Whole
genome sequencing for microbial identification and determination of antimicrobial susceptibility].
All of
the relevant financial relationships listed have been mitigated. Allyson Bloom, MD No hay relación(es)
financiera(s) relevante(s) con compañías no elegibles para revelar.
El grupo editorial revisa las divulgaciones de los contribuyentes en busca de conflictos de intereses.
Cuando se encuentran, estos se abordan mediante la investigación a través de un proceso de revisión de
múltiples niveles y mediante los requisitos para que se proporcionen referencias para respaldar el
contenido. Se requiere que todos los autores tengan contenido referenciado de manera adecuada y debe
cumplir con los estándares de evidencia de UpToDate.
Política de conflicto de intereses

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20/9/22, 00:14 Infecciones urinarias agudas complicadas (incluyendo pielonefritis) en adultos - UpToDate

Reimpresión oficial de UpToDate ®

Infecciones agudas complicadas del tracto urinario

costovertebral y otros signos de enfermedad sistémica) y las infecciones urinarias en

● (Consulte "Cistitis aguda simple en mujeres" .)

Asymptomatic bacteriuria is also discussed in detail elsewhere. (See "Asymptomatic bacteriuria

By this definition, pyelonephritis is a complicated UTI, regardless of patient characteristics. In

We do not automatically consider patients with underlying urologic abnormalities (such as

Increasing rates of resistance in uropathogens have been reported globally. As an example, in

Pyuria is present in almost all patients with UTI.

Xanthogranulomatous pyelonephritis is a rare variant of pyelonephritis in which there is

Evaluation — Acute complicated urinary tract infection (UTI) should be suspected in patients

Pregnancy testing is appropriate in women of childbearing potential when the possibility of

Renal ultrasound is appropriate in patients for whom exposure to contrast or radiation is

Resolution of radiographic hypodensities may lag behind clinical improvement by up to three

The presence of bacteriuria (≥105 colony-forming units/mL of a uropathogen) with or without

Many patients can be managed in the outpatient setting. As an example, in a study of 44

Empiric antimicrobial therapy — The approach to empiric therapy of acute complicated UTI

Critical illness and/or urinary tract obstruction — We use a broad-spectrum antimicrobial

In such patients, we suggest an antipseudomonal carbapenem (imipenem 500 mg

Ultimately, however, the selection of antimicrobial therapy should be individualized. In locations

Advanced cephalosporin or carbapenem combinations with beta-lactamase inhibitors, the novel

● No risk factors for infection with a multidrug-resistant gram-negative organism

● At least one risk factor for infection with a multidrug-resistant gram-negative

Advanced cephalosporin or carbapenem combinations with beta-lactamase inhibitors and

Whether fluoroquinolones can be used (accounting for contraindications or concerns for

● Fluoroquinolone-based regimens – For patients who have no contraindications to

In the case that community prevalence of E. coli fluoroquinolone resistance is known to be

musculoskeletal and neurologic adverse effects associated with fluoroquinolones. (See

● Fluoroquinolone-sparing regimens – For patients who have contraindications to

As above, we prefer ceftriaxone (1 g IV or IM once) as a long-acting parenteral agent

• Trimethoprim-sulfamethoxazole – one double-strength (160 mg/800 mg) tablet orally

For patients who have no contraindications to fluoroquinolones (ie, allergy or expected

Directed antimicrobial therapy

Regimen selection — Results of urine culture and susceptibility testing should be used to

● Enterobacterales (eg, E. coli, K. pneumoniae, P. mirabilis):

• Susceptible isolates – For susceptible Enterobacterales, appropriate oral agents to treat

Options for outpatient administration of parenteral antimicrobials include use of a

Nitrofurantoin, oral fosfomycin, and pivmecillinam should generally be avoided in the

Novel options for outpatient management of resistant gram-negative bacteria are

● Enterococcus – If Enterococcus is isolated, amoxicillin (500 mg orally every eight hours or

● Pseudomonas – Directed therapy of Pseudomonas UTI is discussed in detail elsewhere. (See

and central nervous system", section on 'Treatment'.)

● Staphylococcus – Oral options include trimethoprim-sulfamethoxazole (one double-

Duration — Total duration of antimicrobial therapy generally ranges from 5 to 10 days,

Addressing underlying urinary tract abnormalities — In addition to antimicrobial therapy,

Follow-up — Symptoms should improve promptly if antimicrobial therapy is effective. Among

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● Indications for hospitalization – Outpatient management is acceptable for patients with

• Other hospitalized patients – For hospitalized patients without critical illness or

Use of UpToDate is subject to the Terms of Use.

4. Khawcharoenporn T, Vasoo S, Singh K. Urinary Tract Infections due to Multidrug-Resistant

BMC Fam Pract 2011; 12:36.

Antimicrob Chemother 2012; 67:2523.

inferiority trial in men and women. BMC Med 2017; 15:70.

Our approach to categorizing UTI in adults and adolescents

Special populations with Pregnant women

UTI: urinary tract infection.

* We do not automatically consider patients with underlying urologic abnormalities (such as

Graphic 117508 Version 2.0

Risk factors for multidrug-resistant gram-negative urinary tract infections

Suspect multidrug-resistant gram-negative urinary tract infection in patients with