Complicated Urinary Tract Infection Treatment

What Oral Antibiotics Are Used To Treat An Uncomplicated Uti In Women

The following oral antibiotics are commonly used to treat most uncomplicated UTI infections :

• sulfamethoxazole-trimethoprim

Your doctor will choose your antibiotic based on your history, type of UTI, local resistance patterns, and cost considerations. First-line options are usually selected from nitrofurantoin, fosfomycin and sulfamethoxazole-trimethoprim. Amoxicillin/clavulanate and certain cephalosporins, for example cefpodoxime, cefdinir, or cefaclor may be appropriate options when first-line options cannot be used.

Length of treatment for cystitis can range from a single, one-time dose, to a course of medication over 5 to 7 days. Kidney infections may require injectable treatment, hospitalization, as well as a longer course of antibiotic, depending upon severity of the infection.

Sometimes a UTI can be self-limiting in women, meaning that the body can fight the infection without antibiotics however, most uncomplicated UTI cases can be treated quickly with a short course of oral antibiotics. Never use an antibiotic that has been prescribed for someone else.

In men with symptoms that do not suggest a complicated UTI, treatment can be the same as women. In men with complicated UTIs and/or symptoms of prostatitis are not present, men can be treated for 7 days with a fluoroquinolone . Tailor therapy once urine cultures are available.

Will I Need An Intravenous Antibiotic For A Uti

If you are pregnant, have a high fever, or cannot keep food and fluids down, your doctor may admit you to the hospital so you can have treatment with intravenous antibiotics for a complicated UTI. You may return home and continue with oral antibiotics when your infection starts to improve.

In areas with fluoroquinolone resistance exceeding 10%, in patients with more severe pyelonephritis, those with a complicated UTI who have allergies to fluoroquinolones, or are unable to tolerate the drug class, intravenous therapy with an agent such as ceftriaxone, or an aminoglycoside, such as gentamicin or tobramycin, may be appropriate. Your ongoing treatment should be based on susceptibility data received from the laboratory.

Are You Sure Your Patient Has Pyelonephritis/complicated Urinary Tract Infection What Should You Expect To Find

• Urinary tract infections can be separated into distinct syndromes depending on host characteristics and the presence of symptoms. The syndromes of pyelonephritis, infection of the renal parenchyma, and complicated UTI, infections of the urinary tract in patients with functional or anatomical abnormalities, are covered here. The presence of bacteria in the urine without localizing urinary tract or systemic symptoms of infection is considered asymptomatic bacteriuria, a common condition that increases with advancing age and most often does not require treatment. In a patient with bacteriuria and systemic symptoms of infection without localizing genitourinary symptoms, UTI should be considered as a potential diagnosis however, other causes of the systemic symptoms should also be evaluated, because the urine culture may simply be reflecting asymptomatic bacteriuria.

• Pyelonephritis denotes infection of the renal parenchyma. Symptoms of pyelonephritis include:

  local pain

  systemic signs of infection

These symptoms may or may not be associated with symptoms of cystitis .

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What Happens When A Uti Goes Untreated

Thanks to early diagnosis and proper treatment, the vast majority of lower urinary tract infections result in no complications. However, if left untreated, a UTI can have serious ramifications notes the Mayo Clinic, including:

• Premature birth and low birth weight
• Kidney damage, which can occur is an untreated UTI spreads from the bladder to the kidneys.

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Study Design And Population

This retrospective cohort study evaluated adult patients who were dispensed a prescription for MDF between July 1, 1999 and June 30, 2018, at Kaiser Permanente Colorado . KPCO cares forâ> 650â000 members in Coloradoâs urban and rural areas through a network of medical offices, pharmacies, and contracted facilities. Coded and free-text data on diagnoses, procedures, laboratory tests, medications, hospitalizations, and membership are maintained in KPCOâs administrative and claims databases. At the time of this study, no internal protocols directed the use of MDF for UTI treatment, although fosfomycin was maintained on the formulary and infrequently recommended in multiple-dose regimens for recurrent and/or MDRO infections. This study was approved by the KPCO Institutional Review Board with a waiver of informed consent.

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How Long Does Treatment Last

Treatment for complicated UTIs tends to take longer compared with simple UTIs, and may take between 7 and 14 days. While a course of antibiotics may treat a typical UTI at home, complicated cases may require broad-spectrum, intravenous antibiotics as well as hospitalization.

The exact treatment timeline depends on how soon your body responds to broad-spectrum antibiotics, as well as whether any complications develop.

Complicated UTIs are most common in people predisposed to risks from infections. The following may increase your risk for complicated UTI:

• age, older adults and young children

Latest Antibiotics For Utis

Vabomere

• Vabomere is a combination carbapenem antibiotic and beta-lactamase inhibitor. Vabomere was first approved in August of 2017.
• Vabomere is used for the treatment of adult patients with complicated urinary tract infections due to susceptible Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae species complex.
• Vabomere is given as an intravenous infusion every 8 hours. Dosage adjustments are required in patients with varying degrees of kidney impairment.

Zemdri

• Zemdri is an aminoglycoside antibacterial for the treatment of complicated urinary tract infections, including pyelonephritis. Zemdri was first approved in February of 2015.
• Zemdri is used against certain Enterobacteriaceae in patients who have limited or no alternative treatment options. Zemdri is an intravenous infusion, administered once daily.

See also: Treatment Options for UTIs

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Clinical And Bacteriologic Outcomes

The primary outcome, clinical resolution of signs and symptoms of infection within 30 days of the index date, occurred in 113 of 171 episodes . Clinical resolution varied greatly according to the pathogens isolated in preindex date cultures, ranging from 20.0% with Citrobacter spp to 83.3% with Pseudomonas spp. Clinical resolution occurred in 87 of 131 episodes in females and 28 of 40 episodes in males with no statistically significant difference . Clinical resolution occurred in 92 of 140 episodes with antibiotic use in the previous 90 days and 23 of 31 episodes without antibiotic use in the previous 90 days with no statistically significant difference .

Only 76 episodes had a pre- and postindex date urinary culture within 30 days to assess the secondary outcome of bacteriologic resolution. Of these, bacteriologic resolution occurred in 37 episodes . Bacteriologic resolution was also highly variable according to the isolated pathogen and ranged from 0% with Proteus or Pseudomonas spp to 100% with Enterococcus spp. Bacteriologic resolution occurred in 41 of 74 episodes in females and 9 of 27 episodes in males , with an insignificant trend toward lower rates in men . Bacteriologic resolution occurred in 33 of 69 episodes with antibiotic use in the previous 90 days and 9 of 15 episodes without antibiotic use in the previous 90 days , with no statistically significant difference .

What About Antibiotic Resistance

Resistance rates for antibiotics are always variable based on local patterns in the community and specific risk factors for patients, such as recent antibiotic use, hospital stay or travel. If you have taken an antibiotic in the last 3 months or traveled internationally, be sure to tell your doctor.

High rates of antibiotic resistance are being seen with both ampicillin and amoxicillin for cystitis , although amoxicillin/clavulanate may still be an option. Other oral treatments with reported increasing rates of resistance include sulfamethoxazole and trimethoprim and the fluoroquinolones. Resistance rates for the oral cephalosporins and amoxicillin/clavulanate are still usually less than 10 percent.

Always finish taking your entire course of antibiotic unless your doctor tells you to stop. Keep taking your antibiotic even if you feel better and you think you don’t need your antibiotic anymore.

If you stop your treatment early, your infection may return quickly and you can develop resistance to the antibiotic you were using previously. Your antibiotic may not work as well the next time you use it.

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Treatment Strategies For Recurrent Utis

Recurrent urinary tract infections, defined as three or more UTIs within 12 months, or two or more occurrences within six months, is very common among women these but arent treated exactly the same as standalone UTIs. One of the reasons: Continued intermittent courses of antibiotics are associated with allergic reactions, organ toxicities, future infection with resistant organisms, and more.

Because of this, its strongly recommended that you receive both a urinalysis and urine culture from your healthcare provider prior to initiating treatment. Once the results are in, the American Urological Association suggests that healthcare professionals do the following:

• Use first-line treatments. Nitrofurantoin, TMP-SMX, and fosfomycin are the initial go-tos. However, specific drug recommendations should be dependent on the local antibiogram. An antibiogram is a periodic summary of antimicrobial susceptibilities that helps track drug resistance trends.
• Repeat testing. If UTI symptoms persist after antimicrobial therapy, clinicians should repeat the urinalysis, urine culture, and antibiotic susceptibility testing to help guide further management.
• Try vaginal estrogen. For peri- and post-menopausal women with recurrent UTIs, vaginal estrogen therapy is recommended to reduce risk of future UTIs.

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How Did The Patient Develop Pyelonephritis/complicated Urinary Tract Infection What Was The Primary Source From Which The Infection Spread

• Pyelonephritis and complicated UTI most commonly occur by migration of enteric bacteria from the intestinal tract into the urethra and ascension into the urinary system.

Basic epidemiology

• The term complicated, as opposed to uncomplicated, suggests there is a predisposing reason for the infection, including the presence of abnormal voiding or a foreign body . Known or suspected multi-drug resistance is also a complicating factor.

• Complicated UTI can occur in any gender and at any age but is most common in men after the fifth decade when benign prostatic hypertrophy is present and in both men and women who have voiding abnormalities related to other conditions.

• Most UTIs in young premenopausal nonpregnant women and in young adult men are not complicated.

• UTIs in patients with diabetes or in postmenopausal women should be considered complicated if there is abnormal voiding associated with those conditions.

• Additional factors that suggest complicated UTI include conditions that make treatment more difficult, such as pregnancy, multidrug resistance, and immunosuppression.

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Introduction And Current Guidance

Urinary tract infection is a nonspecific term that refers to infection anywhere in the urinary tract, from the urethra to the bladder and the ureters to the kidneys . According to the European Association of Urology Guidelines on urological infections, complicated urinary tract infections are associated with certain conditions, such as a structural or functional problem with the genitourinary tract, or the presence of underlying disease, which increases the risk of persistent or relapsing infection. Pyelonephritis is an infection of the upper urinary tract and can occur in 1 or both kidneys, usually developing from an ascending infection of the lower urinary tract. Acute pyelonephritis is considered to be complicated in people with increased susceptibility, for example children or older people people with functional or structural abnormalities of the genitourinary tract or people who are immunocompromised, so that the infection will likely be severe .

Complicated urinary tract infections are frequently caused by gramnegative bacteria . According to the European Association of Urology Guidelines on urological infections, second or third generation cephalosporins, betalactam antibiotics in combination with betalactamase inhibitors and quinolones are often used for treating complicated urinary tract infections. However, increasing resistance to commonly prescribed antimicrobial agents is a recognised serious global problem .

Full text of introduction and current guidance.

Antibiotics Used For Uncomplicated Utis

If you are a healthy individual whose urinary tract is anatomically and functionally normal and you have no known heightened UTI susceptibility youve got whats dubbed an uncomplicated UTI, according to guidelines published in August 2019 in the Journal of Urology. For these individuals, antibiotics are considered the first-line of treatment.

The type of antibiotics you are prescribed and for how long is contingent on the type of bacteria detected in your urine, your current health status, and whether your UTI is uncomplicated or complicated. Depending on which antibiotic your doctor prescribes, women may need a single dose or up to a five-day course. For men, antibiotics are usually given for a slightly longer period of time, notes UpToDate.

Typically, if you are diagnosed with an uncomplicated UTI, one of the following will be prescribed as first-line treatment:

The following antibiotics are considered second-line treatments for UTI. They are generally chosen because of resistance patterns or allergy considerations:

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What Other Additional Laboratory Findings May Be Ordered

Elevated procalcitonin has been associated with bacteremia in patients with febrile UTI and proposed as a diagnostic test in lieu of blood cultures. It is not commonly used in clinical practice for this purpose, because blood cultures also give added information about the identity of the infecting pathogen, which should match the urinary pathogen if UTI is the correct diagnosis.

Antibiotics Used For Complicated Utis

Before getting into how to best treat a complicated UTI, its important to understand which UTIs are considered complicated. Here are some guidelines:

• Urinary tract abnormalities are present
• Youre pregnant
• The patient is a child
• A comorbidity is present that increases risk of infection or treatment resistance, such as poorly controlled diabetes
• Youre a man, since most UTIs in men are considered complicated

Kidney infections are often treated as a complicated UTI as well, notes the Merck Manual.

If a UTI is complicated, a different course of antibiotics may be required. And the initial dose of antibiotics may be started intravenously in the hospital. After that, antibiotics are given orally at home. In addition, follow-up urine cultures are generally recommended within 10 to 14 days after treatment. Not all of the antibiotics approved for uncomplicated UTIs are appropriate for the complicated version. Some that are considered appropriate, include:

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Does Cranberry Juice Prevent A Uti

Some patients may want to use cranberry or cranberry juice as a home remedy to treat a UTI. Cranberry juice has not been shown to cure an ongoing bacterial infection in the bladder or kidney.

Cranberry has been studied as a preventive maintenance agent for UTIs. Studies are mixed on whether cranberry can really prevent a UTI. Cranberry may work by preventing bacteria from sticking to the inside of the bladder however, it would take a large amount of cranberry juice to prevent bacterial adhesion. More recent research suggests cranberries may have no effect on preventing a UTI

• According to one expert, the active ingredient in cranberries — A-type proanthocyanidins — are effective against UTI-causing bacteria, but is only in highly concentrated cranberry capsules, not in cranberry juice.
• However, cranberry was not proven to prevent recurrent UTIs in several well-controlled studies, as seen in a 2012 meta-analysis of 24 trials published by the Cochrane group.
• While studies are not conclusive, there is no harm in drinking cranberry juice. However, if you develop symptoms, see your doctor. Some people find large quantities of cranberry juice upsetting to the stomach.

Increasing fluid intake like water, avoiding use of spermicides, and urinating after intercourse may be helpful in preventing UTIs, although limited data is available.

Researchers Involved In Rutgers

An international study led by a Rutgers scientist comparing new and older treatments against complicated urinary tract infections has found a new drug combination to be more effective, especially against stubborn, drug-resistant infections.

Describing the results in the Journal of the American Medical Association , researchers in the ALLIUM Phase 3 clinical trial showed that a combination of the drugs cefepime and enmetazobactam was more effective in treating both complicated urinary tract infections and acute pyelonephritis , a bacterial infection causing kidney inflammation, than a standard treatment combining piperacillin and tazobactam. Urinary tract infections are considered complicated when they are associated with risk factors including fevers, sepsis, urinary obstruction or catheters that increase the danger of failing antibiotic therapy.

This new antibiotic was superior to the standard-of-care therapy, said Keith Kaye, chief of the Division of Allergy, Immunology and Infectious Diseases and a professor of medicine at Rutgers Robert Wood Johnson Medical School.

It represents an exciting option for treatment, said Kaye, the principal investigator of the study and lead author on the publication.

We are looking for antibiotics that are active against resistant bacteria, such as ESBLs, and we found this new combination to be highly effective, Kaye said.

Kaye said he expected the company to apply for FDA approval early next year.

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What Should You Tell The Family About The Patients Prognosis

• Diabetes is associated with xanthogranulomatous, papillary necrosis, and emphysematous pyelonephritis, severe conditions requiring a combined surgical and medical approach.

• Obstruction that cannot be relieved or presence of a stone or stricture increase the likelihood of infection and make treatment of infection more difficult.

• The overall 28-day and 1-year all-cause mortality rates following a UTI associated with gram-negative bacteremia was found to be 4.9% and 15.6% , respectively, in a population-based retrospective study. Mortality rates were higher with advancing age and in patients with health-care acquired infections.

• Catheter associated UTI was the third leading cause of hospital associated infection-related death in US hospitals in 2002.

Add what-if scenarios here:

If the urine culture reveals yeast, assess for symptoms of urinary tract infection because funguria most often represents asymptomatic colonization of the urinary tract . If symptoms of urinary tract infection are present, assess for fungal balls within the urinary tract , control hyperglycemia , and institute anti-fungal therapy. Urology consultation may be needed for removal of fungal balls or irrigation of the urinary system with an antifungal agent .