Optimal Use of Antibiotics in Urology

EAU

IDSA

Fosfomycin trometamol

3 g single dose

Fosfomycin trometamol

3 g single dose

Nitrofurantoin

50 mg q6h × 7 days

Nitrofurantoin monohydrate/macrocrystals

100 mg bid × 5 days

Nitrofurantoin macrocrystal

100 mg bid × 5–7 days

Pivmecillinam

400 mg bid × 3 days

Pivmecillinam

400 mg bid × 5 days

Pivmecillinam

200 mg bid × 7 days

Trimethoprim-sulfamethoxazole

160/800 mg (one DS tablet) bid × 3 days (if resistance prevalence is <20 %)

Alternatives

(If local resistance of E. coli is <20 %)

Trimethoprim-sulphamethoxazole 160/800 mg bid 3 days

Ciprofloxacin 250 mg bid × 3 days

Levofloxacin 250 mg qd × 3 days

Norfloxacin 400 mg bid × 3 days

Ofloxacin 200 mg bid × 3 days

Cefpodoxime proxetil

100 mg bid × 3 days

Trimetoprim 200 mg bid × 5 days

Treatment of Uncomplicated Pyelonephritis

Oral antibiotics can be effective in mild and moderate cases. Treatment should last for 5–10 days preferably with one of the following agents: Ciprofloxacin (500–750 mg bid 7–10 days), Levofloxacin (250–500 mg qd 7–10 days), Levofloxacin (750 mg qd 5 days) [8].

Parenteral administration of antimicrobial agents is indicated for the treatment of severe pyelonephritis. After improvement, oral treatment should be instituted with one of the above-mentioned antibacterials. Initial empiric parenteral treatment should be started with one of the following agents: Ciprofloxacin (400 mg bid), Levofloxacin (250–500 mg qd), Levofloxacin (750 mg qd).

Tip

If a fluoroquinolone, TMP-SMX or a beta-lactam for oral treatment is preferred for the treatment of acute pyelonephritis and the local susceptibility of microorganisms is not known, an initial IV dose of ceftriaxone or 24 dose or aminoglycoside is recommended [5].

Treatment of Pregnant Women with UTI

Tip

Pregnant women should be screened for asymptomatic bacteriuria during the first trimester. Asymptomatic bacteriuria in pregnancy should be treated same as cystitis (Table 11.2).

Table 11.2

Treatment regimens for ABU and pyelonephritis in pregnancy [4]

Asymptomatic bacteriuria in pregnancy	Pyelonephritis in pregnancy
Nitrofurantoin (Macrobid®) 100 mg q12 h, 3–5 days	Ceftriaxone 1–2 g IV or IM q24 h
Amoxicillin 500 mg q8 h, 3–5 days	Aztreonam 1 g IV q8-12 h
Co-amoxicillin/clavulanate 500 mg q12 h, 3 t-5 days	Piperacillin-tazobactam 3.375–4.5 g IV q6 h
Cephalexin (Keflex®) 500 mg q8 h, 3–5 days	Cefepime 1 g IV q12 h
Fosfomycin 3 g Single dose	Imipenem-cilastatin 500 mg IV q6 h
Trimethoprim-sulfamethoxazole q12 h, 3–5 days	Ampicillin 2 g IV q6 h
	Gentamicin 3–5 mg/kg/day IV in 3 divided doses

Tip

Avoid nitrofurantoin in G6PD deficiency, trimethoprim in first trimester and at term, tetracyclines, chloramphenicol and aminoglycosides.

Antibiotics for the Treatment of Complicated UTIs

Complicated UTIs are infections associated with an anatomical or functional abnormality of the genitourinary tract. Therefore, treatment should aim to treat the infection while managing the underlying pathology simultaneously. Guiding the treatment with urine culture is a general and useful recommendation. However, it may be necessary to start with empirical treatment while waiting for urine culture results. In this case, a broad bacterial spectrum has to be considered. A fluoroquinolone with mainly renal excretion, an aminopenicillin plus a β-lactamase inhibitor (BLI), a cephalosporin, carbapenems, aminoglycosides are recommended alternatives [4, 5].

Tip

(EAU): Antibiotics with nephrotoxic features (e.g., aminoglycosides) should be used cautiously in patients with renal impairment. Because of the wide therapeutic index of most antibiotics, adjustment of dose would not be considered unless GFR < 20 mL/min. Nitrofurantoin and tetracyclines are contraindicated, but not doxycycline.

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