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UTI Complicated: Treatment

3 Contact Hours including 3 Pharmacology Hours Hours
Only ARNPs and CNSs will receive credit for this course.
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Clinical Nurse Specialist (CNS)
This course will be updated or discontinued on or before Thursday, September 12, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥ 92% of participants will know how to treat complicated urinary tract infections.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Define the appropriate management of complicated UTI.
  2. Compare and contrast the various therapeutic agents indicated for complicated UTI.
  3. Differentiate between the treatment indicated for hospitalized patients versus that of more critical hospitalized patients.
  4. Explain the outpatient treatment that is recommended for patients who do not require hospitalization for complicated UTIs.
  5. Describe the diagnostic-informed directed antimicrobial therapy for complicated UTI.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Authors:    Pamela Downey (MSN, ARNP) , Alyssa King (Nurse Planner, DNP, APRN, CPNP-PC, CLC)

Introduction

The categorization of a urinary tract infection (UTI) as acute complicated directs the management of care. Management is based on the extent and severity of the infection.

Management

Promptly start empiric antimicrobial therapy. Consider factors for drug resistance, including previous antimicrobial use, and results of recent urine cultures. Adjust the antimicrobial based on culture results. Consult urology for suspected or confirmed anatomic abnormalities.

The choice of initial antimicrobial therapy depends on (Hooten & Gupta, 2021):

  • Susceptibility of prior urinary isolates
  • Patient issues including allergy, personal tolerability, and history of prior antimicrobial use
  • Local community resistance prevalence of Enterobacteriaceae
  • Antimicrobial issues including toxicity, drug interactions with other medications the patient takes, drug availability, and drug cost

Do a urine culture and susceptibility for all patients. The efficacy of different regimens for acute complicated UTIs has only been done on a few regimens. The following antimicrobial agents are those that are most commonly to blame for UTIs.

Microbiology Underlying UTIs

UTIs are caused by both Gram-negative and Gram-positive bacteria, as well as, by certain fungi. The most frequent cause for both uncomplicated and complicated UTIs is uropathogenic Escherichia coli (UPEC) (Flores-Mireles & Walker et al, 2015; Hooten & Gupta, 2021).

  • Microbial agents involved in uncomplicated UTIs and listed according to prevalence include (Flores-Mireles & Walker et al, 2015; Hooten & Gupta, 2021):
    • UPEC 75%
    • Klebsiella pneumoniae 6%
    • Staphylococcus saprophyticus 6%
    • Enterococcus faecalis 5%
    • Group B Streptococcus (GBS) 3%
    • Proteus mirabilis 2%
    • Pseudomonas aeruginosa 1%
    • Staphylococcus aureus 1%
    • Candida spp. 1%
  • Microbial agents involved in acute complicated UTIs and listed according to prevalence include (Flores-Mireles & Walker et al, 2015; Hooten & Gupta, 2021):
    • UPEC 65%
    • Enterococcus spp 11%
    • Group B Streptococcus (GBS) 8%
    • Klebsiella pneumoniae 8%
    • Candida spp. 7%
    • Staphylococcus aureus 3%
    • Proteus mirabilis 2%
    • Pseudomonas aeruginosa 2%

The prevalence of particular pathogens depends partially on the host. As examples (Flores-Mireles & Walker et al, 2015; Hooten & Gupta, 2021):

  • 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.

Risk factors for UTIs with resistant organisms include (Flores-Mireles & Walker et al, 2015; Hooten & Gupta, 2021):

  • Health care exposures
  • Recent broad-spectrum antimicrobial use
  • Travel to parts of the world where multidrug-resistant organisms are prevalent i.e. India, Israel, Spain, and Mexico

Increasing rates of resistance in uropathogens have been reported globally. For examples (Flores-Mireles & Walker et al, 2015; Hooten & Gupta, 2021):

  • In the U.S., one study documented a threefold increase in the prevalence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae among hospitalized patients with UTIs from 2000 to 2009.
  • In another study of patients with pyelonephritis presenting to EDs across the U.S., approximately 6% of the 453 E. coli isolates produced ESBL, although rates varied by region and complicating features. 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 UTIs.
    • In one study of E. coli clinical isolates from extraintestinal sites, predominantly urine, collected at Veterans Affairs (VA) laboratories across the U.S., the ST131 clone accounted for the majority of fluoroquinolone-resistant and ESBL isolates and was calculated to account for 28% of all VA E. coli isolates nationwide.
  • Carbapenem resistance among Enterobacteriaceae has also increased.

The following recommendations for therapeutic agents of treatment are based on expected microbial spectrum that achieves adequate urinary tract and systemic levels.

Therapeutic Agents

When starting empiric antimicrobial therapy, make sure to consider factors for drug resistance, including previous antimicrobial use, and results of recent urine cultures. Once culture results are obtained, then adjust the antimicrobial of treatment.

The following chart includes the various antimicrobial medication groups, their respective mechanism of action, and their specific indication for usage (Hooten & Gupta, 2021; Drew, 2021; Drew & Sakoulas, 2021; Drew & Peel, 2021; Letourneau, 2021a; Letourneau, 2021b; Letourneau, 2021c; Hooper, 2021):

Table 1: Antimicrobial Groups for Treatment
Aminoglycoside Antibiotics:
Mechanism of Action:
Aminoglycosides have concentration-dependent bactericidal activity. They bind to the 30S ribosome, thereby inhibiting bacterial protein synthesis.
Agents:
  • Gentamycin
  • Tobramycin
  • Plazomicin
Indications for usage include:
  • Aerobic, Gram-negative bacteria such as Pseudomonas, Acinetobacter, Enterobacter, and some Mycobacteria
β-lactam Antibiotics:
Mechanism of Action:
β-lactam antibiotics are a class of broad-spectrum antibiotics consisting of all antibiotic agents containing a beta-lactam ring in their molecular structures. Most β-lactam antibiotics inhibit cell wall biosynthesis in bacterial organisms. They are the most widely used group of antibiotics. Resistance to B-lactam bacteria is common. To stop this resistance, β-lactam antibiotics are often given with β-lactamase inhibitors such as clavulanic acid.
Class: Beta-lactamase inhibitors combinations
Agents:
  • Amoxicillin-clavulanate
  • Piperacillin-tazobactam
Indications for usage include:
  • Gram-negative bacteria
Class: Carbapenems
Agents:
  • Imipenem
  • Doripenem
  • Ertapenem
  • Meropenem
Indications for usage include:
  • Haemophilus influenza
  • Anaerobes
  • Most Enterobacteriaceae
  • Methicillin-sensitive staphylococci and streptococci, including S. pneumoniae
  • Most Enterococcus faecalis and many P. aeruginosa strains
  • Carbapenems are active synergistically with aminoglycosides against P. aeruginosa, E. faecium, Stenotrophomonas maltophilia and methicillin-resistant staphylococci
Class: Cephalosporins
Agents:
  • Cefadroxil
  • Cefdinir
  • Cefepime
  • Cefiderocol
  • Cefpodoxime-proxetil
  • Ceftazidime
  • Ceftriaxone
Indications for usage include:
  • Gram-positive bacteria
  • Gram-negative bacteria
Class: Penicillins
Agents:
  • Amoxicillin
  • Pivmecillinam
Indications for usage include:
  • Enterococci: Gram-positive bacteria such as E. faecalis and E. faecium
  • Certain gram-negative bacilli such as non-B-lactamase-producing H. influenza, E. coli, and Proteus mirabilis; Salmonella species; and Shigella species
Co-trimoxazole Antibiotics:
Mechanism of Action:
Trimethoprim and sulfamethoxazole have a synergistic effect when given together. They are given in a one-to-five ratio in their tablet formulations.
Agent:
  • Trimethoprim-Sulfamethoxazole (TMP-SMX)

Indications for usage include:

  • Gram-positive bacteria (including some methicillin-resistant Staphylococcus aureus)
  • A broad spectrum of gram-negative bacteria
  • Protozoans Cystoisospora and Cyclospora species
  • The fungus, Pneumocystis jirovecii
Fluoroquinolone Antibiotics:
Mechanism of Action:
Fluoroquinolones are effective against both Gram-negative and Gram-positive bacteria.
Agents:
  • Ciprofloxacin
  • Ciprofloxacin-extended release
  • Levofloxacin
  • Moxifloxacin
  • Norfloxacin
  • Ofloxacin
Indications for usage include:
  • Haemophilus influenzae
  • Moraxella catarrhalis
  • Mycoplasma species
  • Chlamydia species
  • Chlamydophila species
  • Legionella species
  • Enterobacteriaceae
  • Pseudomonas eruginosa Mycobacterium tuberculosis
  • Some atypical mycobacteria
  • Methicillin-sensitive staphylococci
Glycopeptide Antibiotics:
Mechanism of Action:
Glycopeptide antibiotics inhibit a late stage in bacterial cell wall peptidoglycan synthesis.
Agents:
  • Vancomycin
Indications for usage include:
  • Most gram-positive cocci and bacilli, including all Staphylococcus aureus and coagulase-negative staphylococcal strains, are resistant to penicillins and cephalosporins
  • Many strains of enterococci (via a bacteriostatic mechanism). However, many strains of enterococci and some strains of S. aureus are vancomycin-resistant
  • Methicillin-resistant S. aureus
  • Methicillin-resistant coagulase-negative staphylococci
  • Certain β-lactam – and multidrug-resistant Streptococcus pneumoniae
  • β-Hemolytic streptococci (when β-lactams cannot be used because of drug allergy or resistance)
  • Corynebacterium group JK
  • Viridans streptococci (when β-lactams cannot be used because of drug allergy or resistance)
  • Enterococci (when β-lactams cannot be used because of drug allergy or resistance)
Lipopeptide Antibiotic:
Mechanism of Action:
Daptomycin is a cyclic lipopeptide antibiotic that binds to the bacterial cell membranes, causing rapid membrane depolarization. This depolarization causes rapid concentration-dependent bacterial death.
Agent:
  • Daptomycin
Indications for usage include:
  • Gram-positive bacteria (broad-spectrum activity)
  • Multidrug-resistant gram-positive bacteria (because cross-resistance with other classes of antibiotics does not occur)
  • Vancomycin-resistant Staphylococcus aureus
  • Vancomycin-resistant enterococci
  • Pneumococci with reduced penicillin sensitivity
Oxazolidinone Antibiotics:
Mechanism of Action:
Linezolid is a synthetic antibiotic that inhibits bacterial protein synthesis by binding to rRNA. It inhibits the creation of the initiation complex during protein synthesis, reducing the length of the peptide chains, and decreasing the reaction rate of translation elongation.
Agent:
  • Linezolid
Indications for usage include:
  • Streptococci
  • Enterococci (Enterococcus faecalis and E. faecium)
  • Staphylococci, including strains resistant to other classes of antibiotics
  • Mycobacteria
  • Anaerobes such as Fusobacterium, Prevotella, Porphyromonas, Bacteroides species, or Peptostreptococci
Phosphonic Antibiotics:
Mechanism of Action:
Fosfomycin is bactericidal and inhibits bacterial cell wall biogenesis by inactivating the enzyme UDP-N-acetylglucosamine-3-enolpyruvyltransferase, also known as MurA.

Agent:

  • Fosfomycin
Indications for usage include:
  • Enterococci (Enterococcus faecalis and E. coli)
  • Gram-negatives such as Citrobacter and Proteus
  • Activity against extended-spectrum β-lactamase-producing pathogens, notably ESBL-producing E. coli

Hospitalization

Admission is individualized. Indications for Hospitalization for complicated UTI include (Hooten & Gupta, 2021):

  • Sepsis
  • Critical illness
  • Concerns regarding patient adherence to the treatment plan
  • Inability to maintain oral hydration or take oral medications
  • Marked debility
  • Pain
  • Persistently high fever (e.g., >38.4°C/>101°F)
  • Suspected urinary tract obstruction

Hospitalized Patients with Critical Illness

For patients with critical illness, those who are getting worse on current therapy, or those with a suspected urinary obstruction, admission to the intensive care unit (ICU) is generally indicated.

The empiric antimicrobial regimen selection approach depends on the risk for infection with MDR gram-negative organisms for patients hospitalized with acute complicated UTIs who are not critically ill and do not have a suspected obstruction (Hooten & Gupta, 2021).

In such patients, the following antimicrobial agents are suggested (Hooten & Gupta, 2021):

  • Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours with or without a loading dose to cover MRSA

PLUS

  • An antipseudomonal carbapenem to cover ESBL-producing organisms and Pseudomonas aeruginosa:
    • Imipenem 500 mg IV every six hours OR
    • Meropenem 1 g IV every eight hours OR
    • Doripenem 500 mg IV every 8 hours

Other therapeutic agents that are active for some ESBL-producing Enterobacteriaceae and MDR P. aeruginosa isolates and that are effective for acute complicated UTIs are (Hooten & Gupta, 2021):

  • Advanced cephalosporin or carbapenem combinations with beta-lactamase inhibitors: These therapeutic agents should only be used in select highly resistant infections due to cost and antimicrobial stewardship.

An infectious disease consult is needed if carbapenem resistance is suspected based on prior susceptibility testing results.

The selection of antimicrobial therapy must be individualized. The community prevalence of MDR organisms must be considered. Narrower spectrum regimens may be indicated. Urine culture and susceptibility should be followed to ensure that the regimen is correct. If feasible, narrow-spectrum antibiotics should be used to complete the treatment.

The rationale for broad coverage is the high risk of adverse outcomes if there is an inadequate response to empiric antimicrobial therapy and the increasing prevalence of MDR organisms. There is a high risk of clinical decompensations for patients with a UTI with urinary tract obstruction.

A broad-spectrum antimicrobial regimen should be used for the treatment of patients with acute complicated UTIs who are critically ill but have no risk factors for multi-drug resistance (MDR) (Hooten & Gupta, 2021).

Imaging is needed to evaluate patients with critical illness or obstruction.

Other Hospitalized Patients

The empiric antimicrobial regimen selection approach depends on the risk for infection with MDR gram-negative organisms for patients hospitalized with acute complicated UTI who are not critically ill and do not have a suspected obstruction (Hooten & Gupta, 2021).

For patients with no risk factors for infection with an MDR gram-negative organism, the following antimicrobial agents are favored (Hooten & Gupta, 2021):

  • Ceftriaxone (1 g IV once daily) OR
  • Piperacillin-tazobactam (3.375 g IV every six hours) OR
  • Antimicrobial alternatives include:
    • Oral or parenteral fluoroquinolones:
      • Levofloxacin 750 mg IV or orally daily
      • Ciprofloxacin 400 mg IV twice daily
      • Ciprofloxacin 500 mg orally twice daily
      • Ciprofloxacin extended-release 1000 mg orally once daily

Oral or parenteral fluoroquinolones are alternatives if the urinary isolates within the last three months are susceptible, and the community prevalence of E. coli fluoroquinolone resistance is not higher than 10%.

Other choices are based on the particular pathogen (Hooten & Gupta, 2021):

  • Piperacillin-tazobactam has activity against Enterococcus or Staphylococcus species
    • Use Vancomycin PLUS one of the other gram-negative agents if the patient cannot use piperacillin-tazobactam
  • If drug-resistant gram-positive organisms are suspected because of previous urinary isolates or other risk factors, use Vancomycin (for MRSA) or Linezolid or Daptomycin (for vancomycin-resistant Enterococcus [VRE])
  • Piperacillin-tazobactam or a fluoroquinolone should be chosen if there is a risk of P. aeruginosa (e.g., because of prior urinary isolates or febrile neutropenia)
  • Other antipseudomonal agents are:
    • Cefepime 2 g IV every 12 hours OR
    • Ceftazidime 2 g IV every eight hours

If there is a risk of infection with an MDR gram-negative organism, use the following agents (Hooten & Gupta, 2021):

  • Piperacillin-tazobactam 3.375 mg IV every six hours OR
  • An antipseudomonal carbapenem:
    • Imipenem 500 mg IV every six hours OR
    • Meropenem 1 g IV every eight hours OR
    • Doripenem 500 mg IV every 8 hours

Change the regimen for particular pathogens. Carbapenem is used for patients who have a recent (e.g., within the prior three months) history of infection with ESBL-producing organisms. Vancomycin (for MRSA) or Daptomycin or Linezolid (for VRE) is added if either of these is suspected (because of prior urinary isolates or gram-positive cocci on a current urine gram stain.

Outpatient Treatment

Patients with acute complicated UTIs who can be treated in an outpatient setting include those who are clinically stable and/or have mild to moderate cases of severity (Hooten & Gupta, 2021). In addition, if rehydration and antimicrobials can be used in an outpatient facility or the emergency department and be followed by oral antimicrobials taken after discharge with close follow-up, these patients can also be managed on an outpatient basis.

As briefly discussed above, the empiric outpatient antimicrobial regimen is selected based on the contraindications and risk factors for infection with an MDR organism (ESBL-producing isolates) (Hooten & Gupta, 2021).

A broad spectrum of antimicrobial activity against most uropathogens (including P. aeruginosa) is provided by fluoroquinolones (Hooten & Gupta, 2021). Fluoroquinolones are comparable or superior to other broad-spectrum antimicrobials, including parenteral regimens, but resistance is increasing. The following fluoroquinolone agents are recommended when there is no risk for MDR and no concerns for fluoroquinolones resistance/toxicity (Hooten & Gupta, 2021):

  • Ciprofloxacin 500 mg orally twice daily for 5 to 7 days OR
  • Ciprofloxacin extended-release 1000 mg orally once daily for 5 to 7 days OR
  • Levofloxacin 750 mg orally once daily for 5 to 7 days
  • Moxifloxacin has lower urinary levels than other fluoroquinolones and should not be used
  • Less commonly used fluoroquinolones effective for UTIs include:
    • Ofloxacin
    • Norfloxacin

Give one dose of a long-acting parenteral agent before fluoroquinolone if the community prevalence of fluoroquinolone resistance in Escherichia coli is known to be >10%. These would include (Hooten & Gupta, 2021):

  • Ceftriaxone 1 g IV or IM once OR
  • Ertapenem 1 g IV or IM once OR
  • Gentamicin 5 mg/kg IV or IM once OR
  • Tobramycin 5 mg/kg IV or IM once
    • The aminoglycosides (Gentamicin or Tobramycin 5 mg per kg IV or IM once) are reserved for patients who cannot use ceftriaxone or ertapenem

Educate patients about the adverse effects of uncommon but serious musculoskeletal and neurologic adverse effects associated with fluoroquinolones. When there are no risk factors for MDR but concerns with fluoroquinolones contraindications or resistance/toxicity, the management approach depends on the severity of the illness. For those with a mild infection, a single dose of a long-acting parenteral agent followed by a non-fluoroquinolone oral agent is advocated (Hooten & Gupta, 2021).

For patients who cannot use a fluoroquinolone, one dose of a long-acting parenteral agent is recommended (Hooten & Gupta, 2021):

  • Ceftriaxone 1 g IV or IM once OR
    • This is a preferred agent because of its safety, efficacy, and microbial spectrum
  • Ertapenem 1 g IV or IM once OR
    • This is an alternative for patients with an allergy that precludes ceftriaxone use or expected resistance to ceftriaxone
  • Gentamicin 5 mg/kg IV or IM once OR
  • ​​​​​​​Tobramycin 5 mg/kg IV or IM once
    • The aminoglycosides (Gentamicin or Tobramycin 5 mg per kg IV or IM once) are reserved for patients who cannot use the other two

Following the one dose of a long-acting parenteral agent, one of the following oral agents is recommended (Hooten & Gupta, 2021):

  • TMP-SMX one double-strength (160mg/800mg) tablet orally twice daily for 7 to 10 days OR
  • Amoxicillin-clavulanate 875 mg orally twice daily for 10 to 14 days OR
  • Cefpodoxime-proxetil 200 mg orally twice daily for 10 to 14 days OR
  • Cefdinir 300 mg orally twice daily for 10 to 14 days OR
  • Cefadroxil 1 g orally twice daily for 10 to 14 days

In outpatients who are systemically ill or at risk for more severe illness, the parenteral agents should be continued until culture and susceptibility testing results can guide the selection of an appropriate agent.

For outpatients with acute complicated UTI and risk factors for infection with an MDR gram-negative organism but no contraindications to fluoroquinolones, the following regimen is recommended (Hooten & Gupta, 2021):

  • Ertapenem 1 g IV or IM once (initial dose)

After Ertapenem, recommendations suggest one of the following (Hooten & Gupta, 2021):

  • Ciprofloxacin 500 mg orally twice daily for 5 to 7 days OR
  • Ciprofloxacin extended-release 1000 mg orally once daily for 5 to 7 days OR
  • Levofloxacin 750 mg orally once daily for 5 to 7 days

If the patient cannot take a fluoroquinolone or has a high risk for fluoroquinolone resistance (fluoroquinolone-resistant isolate or fluoroquinolone use in the prior three months), order Ertapenem 1 g IV or IM once daily until cultures and susceptibility testing return.

Use the following antimicrobial agents for outpatients with acute complicated UTI and risk factors for infection with an MDR gram-negative organism and who have either contraindications or concerns for fluoroquinolone resistance:

  • Ertapenem 1 g IV or IM daily in the outpatient setting until culture and susceptibility testing results return
  • Plazomicin once-daily is an alternative

Directed Antimicrobial Therapy

Change a parenteral regimen to an oral regimen once symptoms have improved. Appropriate oral agents to treat acute complicated UTIs include (Hooten & Gupta, 2021):

  • Levofloxacin 750 mg orally once daily
  • Ciprofloxacin 500 mg orally twice daily or 1000 mg extended-release once daily
  • TMP-SMX one double-strength [160 mg/800 mg] tablet orally twice daily
  • Oral beta-lactams are less effective but are appropriate if susceptibility is documented and the other agents are not feasible
  • If Enterococcus is isolated:
    • Amoxicillin 500 mg orally every eight hours or 875 mg orally twice daily
    • Fosfomycin and Pivmecillinam should be avoided because they do not achieve adequate tissue levels outside the bladder.

Occasionally, susceptibility results require a parenteral agent to complete the course of treatment. Outpatient administration of parenteral antimicrobials includes a peripherally inserted central catheter, a preexisting central catheter, or IM injection.

The duration of antimicrobial therapy ranges between 5 to 14 days. The duration depends on the rapidity of clinical response and the antimicrobial chosen to complete the course (Hooten & Gupta, 2021). The following are the general durations of treatment for the listed respective drugs (Hooten & Gupta, 2021):

  • Fluoroquinolones are given for 5 to 7 days
  • TMP-SMX is given for 7 to 10 days
  • Beta-lactams are given for 10 to 14 days

Longer treatment duration is needed in patients with a nidus of infection, such as a non-obstructing stone that cannot be removed. The duration of antimicrobial therapy need not be extended due to bacteremia in the absence of other complicating factors. There is no evidence that bacteremia portends a worse prognosis (Hooten & Gupta, 2021).

Research indicates that fluoroquinolones' five- or seven-day duration is comparable to longer durations. Limited data evaluate the use of other oral agents for acute complicated UTIs (Hooten & Gupta, 2021).

Underlying Urinary Tract Abnormalities

Antimicrobials alone may not be successful unless such underlying conditions are corrected. Examples of types of urinary obstruction include (Hooten & Gupta, 2021):

  • Underlying anatomical urinary tract abnormalities
  • Underlying functional urinary tract abnormalities like neurogenic bladder
  • Indwelling bladder catheters
  • Nephrostomy tubes
  • Urethral stents

Additional management for these patients may be needed. Examples of additional methods of management or intervention include (Hooten & Gupta, 2021):

  • Increase frequency of catheterization to improve urinary flow
  • Exchange or removal of a catheter
  • Urologic consultation
  • Gynecologic consultation

Follow-Up

If antimicrobial therapy is effective, symptoms should improve quickly. It is important that these patients are closely followed. It is recommended that contact is made by telephone or face-to-face within 48-72 hours with outpatients who had pyelonephritis.

Additional evaluation is needed if symptoms worsen after starting antimicrobials, symptoms persist after 48 to 72 hours of treatment, or symptoms recur within a few weeks. This evaluation includes abdominal/pelvic imaging 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 (Hooten & Gupta, 2021). Patients who presented with hematuria repeat the urinalysis several weeks after treatment to check for persistent hematuria.

Case Study: Mrs. Vinge

Scenario/Situation/Patient Description

Mrs. Vinge is a 63-year-old, retired, widowed, not sexually active, Caucasian female who comes to Urgent Care with c/o increasing fatigue, lower back pain with fevers to 103.5◦ self-treated with Tylenol 500 mg PO every 12 hours for the past three days.

This morning upon first urination, she reports gross hematuria. Denies frequency, urgency, dysuria, vaginal discharge, or itching. No sexual activity in the past 20 years. LMP 1999. No travel outside of the country since 2006. No urinary procedures during her entire lifetime. She denies having any prior UTIs in her lifetime.

PMH:

  • Osteoporosis diagnosed in 2005
  • C-section March 1979
  • T&A 1955

NKDA

Current medications:

  • Ibandronate sodium 150 mg once a month
  • Vitamin D one capsule po q day
  • Tylenol 500 mg po prn
  • Motrin 200 mg po prn

Physical Examination

Febrile: 102.5 PO-last Tylenol 4 hours ago.

Neuro: Alert, oriented, cooperative, follows all commands appropriately. PERRLA.

HEENT: WNL

Lungs: CTA. No rales, rhonchi, or wheezes.

Cardiac: HR 100 regular, regularity. No murmurs nor rubs. BP 130-140/70-84.

Abdominal: Abdomen soft, non-tender, with bowel sound in all quadrants. CVA tenderness bilaterally.

GU: Urine cloudy with gross hematuria.

PVS: No edema.

Interventions/Strategies

Urine dipstick: leukocyte esterase positive; Nitrite positive

Midstream urine specimen collected and sent to the lab for urine culture and susceptibility.

Discussion of Outcomes

Results of urine culture showed Escherichia coli > 105 CFU units/mL.

Urine susceptibility testing: This shows E. Coli is sensitive to fluoroquinolone antibiotics.

Strengths & Weaknesses

The patient is considered low risk for infection with an MDR gram-negative organism.

Since the community prevalence of fluoroquinolone resistance in E. Coli is <10%, Ciprofloxacin 500 mg orally twice daily for 7 days is prescribed.

Follow-up should be scheduled with her Primary Care physician in seven days or sooner should symptoms worsen.

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References

  • Drew, R. (2021, November). Aminoglycosides. UpToDate. Visit Source.
  • Drew, R., & Sakoulas, G. (2021, November). Vancomycin: Parenteral dosing, monitoring, and adverse effects in adults. UpToDate. Visit Source.
  • Drew, R., & Peel, T. (2021, November). Linezolid and tedizolid (oxazolidinones): An overview. UpToDate. Visit Source.
  • Flores-Mireles, A., Walker, J., Caparon, M., & Hultgren, S. (2015). Urinary tract infections: Epidemiology, mechanisms of infection, and treatment options. Nature Reviews Microbiology. 13 (5): 269-284. Visit Source.
  • Hooper, D. (2021, November). Fluoroquinolones. UpToDate. Visit Source.
  • Hooton, T., & Gupta, K. (2021, November). Acute complicated urinary tract infection (including pyelonephritis) in adults. UpToDate. Visit Source.
  • Letourneau, A. (2021a, November) Beta-lactam antibiotics: Mechanisms of action and resistance and adverse effects. UpToDate. Visit Source.
  • Letourneau, A. (2021b, November). Combination beta-lactamase inhibitors, carbapenems, and monobactams. UpToDate. Visit Source.
  • Letourneau, A. (2021c, November). Cephalosporins. UpToDate. Visit Source.