Complicated Infection

Complicated UTIs are characterized by signs and symptoms of upper tract (i.e., renal) involvement or by factors that predispose to upper tract involvement. UTIs with signs of renal or systemic involvement are also called pyelonephritis. Most cases of pyelonephritis are caused by ascending bacterial infection from the bladder (Ramakrishnan and Scheid, 2005).

Symptoms include fever, flank pain, nausea, vomiting, and costovertebral angle tenderness. Findings such as pyuria are typical, and urine culture is usually positive. White cell casts may be present on urine microscopy. Hospitalized patients with UTIs are best managed based on culture results. E. coli is the typical pathogen for uncomplicated outpatient UTIs and pyelonephritis. E. coli is still the most common isolate in hospitalized patients, but now to a lesser extent, as

Table 40-11 Treatment Options for Acute Uncomplicated UTIs Table 40-12 Antibiotics for Uncomplicated UTI Prophylaxis

Medication

Dose

Regimen

Duration

Trimethoprim/ sulfamethoxazole (Bactrim DS, Cotrim DS, Septra DS)

160/800 mg

Twice daily

3 days

Trimethoprim (Primsol)

100 mg

Twice daily

3 days

Nitrofurantoin macrocrystals (Macrodantin)

SO or 100 mg

4 times daily

7 days

Nitrofurantoin monohydrate macrocrystals (Macrobid)

100 mg

Twice daily

7 days

Ciprofloxacin (Cipro)

2S0 mg

Twice daily

3 days

Gatifloxacin (Tequin)

400 mg

Daily

1 single dose or 3 days

Lomefloxacin (Maxaquin)

400 mg

Twice daily

3 day

Levofloxacin (Levaquin)

2S0 mg

Once daily

3 days

Norfloxacin (Noroxin)

400 mg

Twice daily

3 day

Fosfomycin (Monurol)

3 g

Single dose

Single dose

From Fihn SD. Acute uncomplicated urinary tract infection in women. N Engl J Med 2003;349:259-266.

UTIs, Urinary tract infections; DS, double strength.

From Fihn SD. Acute uncomplicated urinary tract infection in women. N Engl J Med 2003;349:259-266.

UTIs, Urinary tract infections; DS, double strength.

Drug Pediatric Dose Adult Dose*

Amoxicillin 10 mg/kg, once daily N/A

TMP-SMX 2 mg/kg, once daily Single strength (80/400 mg), based on TMP half-tablet at night or three times weekly

Trimethoprim N/A 100 mg nightly

Nitrofurantoin 1-2mg/kg, once daily 50 or 100 mg nightly

Norfloxacin N/A 200 mg nightly

Postcoital prophylaxis options: TMP-SMX, nitrofurantoin, fluoroquinolones. TMP-SMX, Trimethoprim-sulfamethoxazole; N/A, not applicable.

Enterococcus, Pseudomonas, and Staphylococcus species become more likely (Graham and Galloway, 2001; Scholes et al., 2005). Blood cultures do not necessarily change management (Ramakrishnan and Scheid, 2005). Imaging, such as renal ultrasonography, is sometimes recommended, but it also does not necessarily change management and thus can be employed at clinical discretion (Nicolle, 2008).

Outpatients can be managed with an oral fluoroquinolone. Hospitalized patients should receive a fluoroquinolone, an aminoglycoside with or without ampicillin, or an extended-spectrum cephalosporin with or without an aminoglycoside. Patients with cultures showing gram-positive cocci should receive ampicillin-sulbactam with or without an aminoglycoside (Warren et al., 1999). Treatment for 7 to 14 days is usually adequate. Resistant bacteria and renal calculi are the most common causes of treatment failure (Ramakrishnan and Scheid, 2005).

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