genitourinary disorders
Bacterial Urinary Tract Infections
Treatment of Bacterial UTIs
Antibiotics Occasionally surgery (eg, to drain abscesses, correct underlying structural abnormalities, or relieve obstruction) All forms of symptomatic bacterial urinary tract infection (UTI) require antibiotics. For patients with troublesome Dysuria , Choice of antibiotic should be based on the patient’s allergy and adherence history, local resistance patterns (if known), antibiotic availability and cost, and patient and provider tolerance for risk of treatment failure. Propensity for inducing antibiotic resistance should also be considered. When urine culture is done, choice of antibiotic should be modified when culture and sensitivity results are available to the most narrow-spectrum drug effective against the identified pathogen. Surgical correction is usually required for Obstructive Uropathy , anatomic abnormalities, and neuropathic urinary tract lesions such as 100 mg orally twice a day for 7 days. All sex partners within 60 days should be evaluated. Men diagnosed with urethritis should be tested for Treatment and First-line treatment ofuncomplicatedcystitis in patients who do not have risk factors for a multidrug-resistant gram-negative organism isnitrofurantoin100 mg orally twice a day for 5 days (it is contraindicated if creatinine clearance is<60 mL/min),trimethoprim/sulfamethoxazole (TMP/SMX) 160/800 mg orally twice a day for 3 days, orfosfomycin3 g orally once. Less desirable choices include a fluoroquinolone or a beta-lactam antibiotic. If cystitis recurs within a week or two, a broader spectrum antibiotic (eg, a fluoroquinolone) can be used and the urine should be cultured. Complicatedcystitis should be treated with empiric broad-spectrum antibiotics chosen based on local pathogens and resistance patterns and adjusted based on culture results. Urinary tract abnormalities must also be managed. Treatment depends on clinical findings and urine culture results: Women with Dysuria , pyuria, and colony growth of Women who have dysuria and pyuria with no bacteriuria should be evaluated for an Overview of Sexually Transmitted Infections (including for Women who have dysuria but neither pyuria nor bacteriuria do not have the true urethral syndrome. They should be evaluated for noninfectious causes of Dysuria . Evaluation may include therapeutic trials, for example, of behavioral treatments (eg, biofeedback and pelvic musculature relaxation), surgery (for urethral stenosis), and medications (eg, hormone replacement for suspected atrophic urethritis, anesthetics, antispasmodics). Typically, asymptomatic bacteriuria in patients with diabetes, older patients, or patients with chronically Catheter-Associated Urinary Tract Infections should not be treated. However, patients at risk of complications from asymptomatic bacteriuria (see Antibiotics are required. Outpatient treatment with oral antibiotics is possible if all of the following criteria are satisfied: Patients are expected to be adherent Patients are immunocompetent Patients have no nausea or vomiting or evidence of Volume Depletion or septicemia Patients have no factors suggesting complicated UTI 10% of the uropathogens in the community are resistant. A second option is usually TMP/SMX 160/800 mg orally twice a day for 14 days ( Treatment references ). However, local sensitivity patterns should be considered because in some parts of the United States, ( Treatment references ), broad-spectrum cephalosporins (eg, Parenteral therapy is continued until defervescence and other signs of clinical improvement occur. In>80% of patients, improvement occurs within 72 hours. Oral therapy can then begin, and the patient can be discharged for the remainder of a 7- to 14-day treatment course. Complicated cases require longer courses of IV antibiotics with total duration of 2 to 3 weeks and urologic correction of anatomic defects. Outpatient management can be considered in pregnant women with pyelonephritis, but only if symptoms are mild, close follow-up is available, and (preferably) pregnancy is<24 weeks' gestation. Outpatient treatment is with cephalosporins. Otherwise, first-line IV antibiotics include cephalosporins,aztreonam, orampicillinplusgentamicin. If pyelonephritis is severe, possibilities includepiperacillin/tazobactamormeropenem. Fluoroquinolones and TMP/SMX should be avoided. Because recurrence is common, some authorities recommend prophylaxis after the acute infection resolves withnitrofurantoin100 mg orally orcephalexin250 mg orally every night during the remainder of the pregnancy and for 4 to 6 weeks after pregnancy. 1.Gupta K, Hooton TM, Naber KG, et al: International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.Clin Infect Dis52(5):e103-120, 2011. doi: 10.1093/cid/ciq257 2.Wagenlehner FME, Cloutier DJ, Komirenko AS, et al: Once-dailyplazomicinfor complicated urinary tract infections.N Engl J Med380(8):729-740, 2019. doi: 10.1056/NEJMoa1801467 