Do we give empirical antibiotics in cases of urinary retention?

From the Guidelines

Empirical antibiotics are not routinely recommended for uncomplicated urinary retention alone. The primary management of urinary retention should focus on bladder decompression through catheterization (intermittent or indwelling) and addressing the underlying cause 1. Antibiotics should only be prescribed if there are signs of urinary tract infection (UTI) such as fever, dysuria, cloudy or foul-smelling urine, or positive urine culture results.

When infection is suspected in catheterized patients or those with urinary retention, common empiric regimens include nitrofurantoin 100mg twice daily, trimethoprim-sulfamethoxazole 160/800mg twice daily, or fluoroquinolones like ciprofloxacin 500mg twice daily for 5-7 days, considering local resistance rates 1. For complicated cases or suspected pyelonephritis, broader coverage with ceftriaxone 1-2g daily or an aminoglycoside may be appropriate, taking into account the latest guidelines from the European Association of Urology 1.

Key considerations in the management of urinary retention and potential UTI include:

• Collecting a urine sample for culture before starting antibiotics when infection is suspected, but not delaying treatment in symptomatic patients
• Avoiding unnecessary antibiotic use to prevent antimicrobial resistance and adverse effects like Clostridioides difficile infection
• Following the most recent guidelines for empirical antimicrobial therapy, such as those provided by the European Association of Urology 1
• Considering local resistance patterns and individual patient factors when selecting an antibiotic regimen, as highlighted in the guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis 1.

From the FDA Drug Label

When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to empiric selection of therapy Urinary Tract Infections: For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris

The FDA drug label does not answer the question.

From the Research

Empirical Antibiotics in Urinary Retention

• The use of empirical antibiotics in cases of urinary retention is a topic of interest, with various studies providing insights into the management of urinary tract infections (UTIs) 2, 3, 4, 5, 6.
• According to a study published in 2003, empirical short-course therapy is preferred for the management of acute cystitis, but evolving resistance requires continuing reassessment of optimal antimicrobial selection 2.
• Another study published in 2020 recommends the use of nitrofurantoin, fosfomycin tromethamine, or pivmecillinam as first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females 3.
• A study published in 1997 found that both ciprofloxacin and ceftazidime were equally effective in preventing infective complications in patients with urinary retention undergoing transurethral resection of the prostate (TURP) 4.
• However, a more recent study published in 2022 highlights the increasing resistance among members of Enterobacterales responsible for outpatient UTIs, limiting the effectiveness of empirical treatment with existing antibiotics 5.
• Another study published in 2018 found that ceftriaxone treatment of complicated UTIs was associated with a higher risk of enterococcal re-infection and prolonged hospitalization 6.

Key Findings

• Empirical antibiotics may be used in cases of urinary retention, but the choice of antibiotic should be guided by local susceptibility patterns and the patient's underlying health status 2, 3.
• The use of broad-spectrum antibiotics such as ceftriaxone should be carefully considered due to the risk of enterococcal re-infection and prolonged hospitalization 6.
• Nitrofurantoin, fosfomycin tromethamine, and pivmecillinam are recommended as first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females 3.
• The increasing resistance among members of Enterobacterales responsible for outpatient UTIs highlights the need for culture-guided treatment and the development of new antibiotics 5.