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:
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
