What is the recommended treatment for a urinary tract infection (UTI) following a dilation and curettage (D&C) procedure?

Treatment of UTI Following D&C Procedure

For patients with UTI following a D&C procedure, empirical broad-spectrum antibiotic therapy against Enterobacteriaceae and Enterococci should be initiated promptly, with subsequent adjustment based on urine culture results. 1

Initial Assessment and Management

• Obtain urine culture before starting antibiotics to guide targeted therapy
• Initiate empiric antibiotic treatment immediately while awaiting culture results
• Consider catheter removal or replacement if a urinary catheter is present, as this is crucial for clinical cure 2

First-Line Antibiotic Options

Oral Options (for non-severe infections):

1. Trimethoprim-sulfamethoxazole (TMP-SMX):

   • Dosage: 160/800 mg (1 DS tablet) twice daily for 10-14 days 3
   • Adjust for renal impairment: reduce to half dose for CrCl 15-30 mL/min; avoid if CrCl <15 mL/min 3

2. Nitrofurantoin:

   • Dosage: 100 mg twice daily for 5-7 days 4, 5
   • Avoid in patients with renal impairment (CrCl <30 mL/min) or if Proteus mirabilis is suspected 2

3. Fosfomycin:

   • Dosage: 3 g single oral dose 4, 5
   • May be less effective than multi-day regimens based on recent evidence 6

Parenteral Options (for severe infections):

1. Ceftriaxone:

   • Dosage: 1-2 g once daily 2
   • Effective against most common uropathogens following gynecological procedures

2. Ciprofloxacin:

   • Dosage: 400 mg IV twice daily 2
   • Reserve as second-line due to resistance concerns 4, 5

3. Piperacillin/tazobactam:

   • Dosage: 3.375-4.5 g every 6-8 hours 2
   • For more severe infections or suspected resistant organisms

Treatment Duration

• Standard UTI following D&C: 5-7 days of appropriate antibiotics 1
• Complicated UTI or signs of systemic infection: 10-14 days 2
• With adequate source control: Short-course therapy (3-5 days) with early re-evaluation is recommended 1

Special Considerations

For Resistant Organisms

If multidrug-resistant organisms are suspected or confirmed:

• ESBL-producing organisms: Consider ceftazidime-avibactam (2.5 g IV q8h) or meropenem-vaborbactam (4 g IV q8h) 1
• Carbapenem-resistant Enterobacteriaceae: Consider plazomicin (15 mg/kg IV q12h) 1

For Catheter-Associated UTI

• Remove or replace the catheter if possible 2
• If catheter must remain, initiate empiric antibiotics and continue until culture results are available 1
• Consider surveillance urine culture 1 week after completing antibiotic therapy 2

Follow-up

• Obtain follow-up urine culture 1 week after completing therapy to ensure resolution 2
• Consider prophylaxis if recurrent UTIs develop following D&C

Common Pitfalls to Avoid

1. Delaying treatment: Post-D&C UTIs can progress rapidly; initiate empiric therapy promptly
2. Inadequate duration: Ensure complete treatment course to prevent recurrence
3. Failing to adjust therapy: Always modify antibiotics based on culture results
4. Overlooking catheter removal: If a urinary catheter is present, removal or replacement is essential for cure

By following this treatment algorithm, clinicians can effectively manage UTIs following D&C procedures, reducing the risk of complications and ensuring optimal patient outcomes.