From the Guidelines
A complicated urinary tract infection (UTI) is indicated by symptoms such as fever, chills, flank pain, nausea, vomiting, and altered mental status, in addition to typical UTI symptoms like dysuria, suprapubic tenderness, and irritative voiding symptoms, and requires aggressive treatment with intravenous antibiotics and possible hospitalization, as recommended by the European Association of Urology guidelines 1. The symptoms of a complicated UTI can vary, but they often include:
- Fever
- Chills
- Flank pain
- Nausea
- Vomiting
- Altered mental status
- Dysuria
- Suprapubic tenderness
- Irritative voiding symptoms Additional risk factors that may indicate a complicated UTI include:
- Anatomical abnormalities, such as obstruction at any site in the urinary tract, foreign body, incomplete voiding, vesicoureteral reflux, or recent history of instrumentation 1
- Underlying medical conditions, such as diabetes mellitus, immunosuppression, or pregnancy 1
- History of healthcare-associated infections or multidrug-resistant organisms isolated 1
- ESBL-producing organisms isolated 1 Treatment for complicated UTIs typically involves:
- Intravenous antibiotics, such as ceftriaxone, piperacillin-tazobactam, or meropenem, for 7-14 days 1
- Oral antibiotics, such as ciprofloxacin or trimethoprim-sulfamethoxazole, to complete a 10-14 day course 1
- Hospitalization, especially for patients with sepsis, kidney involvement, pregnancy, or immunocompromised status 1
- Management of any underlying urological abnormality or complicating factor, as recommended by the European Association of Urology guidelines 1 It is essential to note that the treatment duration should be closely related to the treatment of the underlying abnormality, and a shorter treatment duration may be considered in cases where short-course treatment is desirable due to relative contraindications to the antibiotic administered 1.
From the FDA Drug Label
1.3 Uncomplicated and Complicated Urinary Tract Infections (including pyelonephritis) Cefepime Injection is indicated for uncomplicated and complicated urinary tract infections (including pyelonephritis) caused by Escherichia coli or Klebsiella pneumoniae, when the infection is severe, or caused by Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis, when the infection is mild to moderate, including cases associated with concurrent bacteremia with these microorganisms.
The symptoms that would indicate a complicated UTI in addition to dysuria, suprapubic tenderness, and irritative voiding symptoms are not explicitly stated in the provided drug labels. However, based on the indication for cefepime injection for complicated urinary tract infections, including pyelonephritis, it can be inferred that the presence of pyelonephritis or severe infection may indicate a complicated UTI.
Additional risk factors that would indicate a complicated UTI are not explicitly stated in the provided drug labels. However, it can be inferred that the presence of concurrent bacteremia or severe infection may be associated with a higher risk of complications 2.
- Key symptoms and risk factors:
- Pyelonephritis
- Severe infection
- Concurrent bacteremia
- Presence of underlying conditions that may increase the risk of complications, such as recent bone marrow transplantation, hypotension at presentation, underlying hematologic malignancy, or severe or prolonged neutropenia 2.
From the Research
Symptoms of Complicated UTI
- In addition to dysuria, suprapubic tenderness, and irritative voiding symptoms, other symptoms that may indicate a complicated UTI include:
- Fever and back pain/costovertebral angle tenderness, which are typically associated with pyelonephritis 3
- Systemic symptoms such as sepsis or urosepsis, which can occur in patients with complicated UTIs 4
- Pyuria, which is usually present with UTI, regardless of location, and its absence suggests that another condition may be causing the patient's symptoms 3
Risk Factors for Complicated UTI
- Additional risk factors that may indicate a complicated UTI include:
- Comorbid conditions or other predisposing factors, such as anatomic or functional abnormalities of the urinary tract 5
- Frequency of sexual intercourse, which is the strongest predictor of recurrent urinary tract infections in patients presenting with recurrent dysuria 5
- Presence of certain organisms, such as Klebsiella, Pseudomonas, Proteus, and other organisms, which are more common in patients with certain risk factors for complicated urinary tract infections 5
- Antimicrobial resistance, which can complicate treatment choices in certain areas 3, 4
Treatment Options for Complicated UTI
- Treatment options for complicated UTIs may include:
- Broad-spectrum antibiotics initially, with urine culture to guide subsequent therapy, and renal imaging studies if structural abnormalities are suspected 5
- Alternative antibiotics, such as carbapenems, which are considered the current last line of therapy, but carbapenem resistance represents a growing problem 6
- Novel treatment options, such as cefepime + enmetazobactam, which may represent an effective carbapenem-sparing treatment option in patients with complicated UTI including acute pyelonephritis 6