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

Treatment of Pseudomonas Urinary Tract Infections

For Pseudomonas UTIs, the recommended treatment is a 10-day course of levofloxacin (if local resistance is <10%) or combination therapy with an anti-pseudomonal β-lactam plus an aminoglycoside for complicated cases with systemic symptoms. 1

Initial Assessment and Diagnosis

• Obtain urine culture and susceptibility testing before starting antibiotics to confirm Pseudomonas aeruginosa and determine antimicrobial susceptibility
• Evaluate for complicating factors that may affect treatment approach:
  • Urinary tract abnormalities
  • Foreign bodies (catheters, stents)
  • Immunosuppression
  • Recent hospitalization or antibiotic exposure
  • History of multidrug-resistant organisms

Treatment Algorithm

Uncomplicated Pseudomonas UTI

• First-line oral therapy (if susceptible and patient stable):
  • Levofloxacin 750 mg daily for 7-10 days 2
  • Only use if local resistance rates <10% and patient hasn't used fluoroquinolones in the last 6 months 1

Complicated Pseudomonas UTI with systemic symptoms

• First-line parenteral therapy:
  • Combination therapy with one of the following 1:
    • Amoxicillin plus an aminoglycoside
    • Second-generation cephalosporin plus an aminoglycoside
    • Intravenous third-generation cephalosporin
  • For documented Pseudomonas, combination with an anti-pseudomonal β-lactam is strongly recommended 1
  • Treatment duration: 7-14 days (14 days for men when prostatitis cannot be excluded) 1

Catheter-Associated Pseudomonas UTI

• Remove or replace catheter if possible
• Higher risk of febrile infection (66.7% vs 40.5% in non-catheterized patients) 3
• Follow complicated UTI treatment recommendations above
• Address underlying urological abnormalities 1

Special Considerations

• Multidrug-resistant Pseudomonas: Treatment options include 4, 5:

  • Ceftazidime or cefepime (if susceptible)
  • Piperacillin-tazobactam
  • Carbapenems (meropenem, imipenem)
  • Ceftolozane-tazobactam or ceftazidime-avibactam (newer agents)
  • Aminoglycosides (as part of combination therapy)
  • Colistin (for highly resistant strains)

• Duration of therapy:

  • 7 days if patient becomes hemodynamically stable and afebrile for at least 48 hours 1
  • Extended to 14 days for complicated cases or when prostatitis cannot be excluded in men 1

Monitoring and Follow-up

• Adjust therapy based on culture results and clinical response
• Monitor for clinical improvement (resolution of symptoms, normalization of temperature)
• Consider repeat urine culture in complicated cases to confirm eradication
• Evaluate and address any underlying urological abnormalities that may predispose to recurrent infection 1

Important Caveats

• Pseudomonas aeruginosa can rapidly develop resistance during treatment, particularly when initial MIC is >0.5 mg/L 6
• Fluoroquinolone resistance is increasing; avoid empiric use if patient has had fluoroquinolone exposure in the past 6 months 1
• Catheterized patients have significantly higher rates of febrile UTIs with Pseudomonas (66.7% vs 40.5%) 3
• Antimicrobial stewardship is crucial to prevent further resistance development 7
• Management of underlying urological abnormalities is mandatory for successful treatment 1