What is the recommended treatment for upper urinary tract infections (UTIs)?

Treatment of Upper Urinary Tract Infections

Fluoroquinolones (e.g., levofloxacin 750 mg daily for 7 days) are the recommended first-line treatment for upper urinary tract infections, with dosing adjustments based on renal function. 1

Diagnosis and Classification

Upper UTIs (pyelonephritis) are typically classified as complicated UTIs, requiring more extensive evaluation and treatment than lower UTIs. Key diagnostic considerations include:

• Urine culture with antimicrobial susceptibility testing is essential before starting treatment 1
• Imaging may be necessary to identify structural abnormalities
• Assessment of underlying conditions that may complicate treatment

Treatment Algorithm

First-line Treatment:

• Fluoroquinolones (e.g., levofloxacin 750 mg daily) for 7 days 1, 2
  • Adjust dosing based on creatinine clearance:
    • ≥50 mL/min: standard dosing
    • 26-49 mL/min: 500 mg once daily
    • 10-25 mL/min: 250 mg once daily

Alternative Options:

• Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 10-14 days if susceptibility is confirmed and local resistance rates are <20% 1, 3

For Resistant Organisms:

• For ESBL-producing organisms: consider carbapenems, ceftazidime-avibactam, or ceftolozane-tazobactam 4, 5
• For AmpC β-lactamase-producing organisms: options include cefepime, piperacillin-tazobactam, or carbapenems 5

Special Considerations

Hospitalization Criteria:

• Inability to tolerate oral medications
• Signs of sepsis or severe illness
• Concern for compliance with oral regimen 1

Population-Specific Considerations:

• Pregnancy: Avoid TMP-SMX in first trimester and near term 1
• Renal insufficiency: Adjust antibiotic doses based on creatinine clearance 1
• Elderly patients: May present with atypical symptoms such as altered mental status, functional decline, fatigue, or falls 1

Follow-up and Prevention

• Perform culture and susceptibility testing periodically during therapy to monitor treatment efficacy and detect emerging resistance 2
• Consider urological evaluation for recurrent or complicated UTIs 1
• For recurrent UTIs, preventive strategies include:
  • Increased fluid intake (at least 2L daily)
  • Vaginal estrogen for postmenopausal women
  • Prophylactic antibiotics in selected cases 1

Common Pitfalls to Avoid

• Failure to obtain cultures before starting antibiotics: Culture results are essential for guiding appropriate therapy, especially in complicated UTIs 1
• Inadequate treatment duration: Upper UTIs require longer treatment courses (7-14 days) compared to lower UTIs 1
• Overuse of fluoroquinolones: Despite being first-line for upper UTIs, fluoroquinolones should be used judiciously due to increasing resistance rates and potential adverse effects 4, 5
• Neglecting to adjust doses for renal function: Improper dosing can lead to treatment failure or toxicity 1

Remember that upper UTIs are serious infections that can lead to significant morbidity if not properly treated. Prompt initiation of appropriate antibiotics based on local resistance patterns and patient factors is essential for optimal outcomes.