What is the recommended treatment for Pseudomonas (Pseudomonas aeruginosa) urinary tract infection (UTI)?

Treatment of Pseudomonas Urinary Tract Infections

For Pseudomonas aeruginosa urinary tract infections, the recommended treatment is ceftolozane/tazobactam or ceftazidime/avibactam for difficult-to-treat resistant strains, while ciprofloxacin, piperacillin/tazobactam, or an aminoglycoside may be used for susceptible strains. 1, 2

Initial Approach

• Obtain urine culture and susceptibility testing before initiating treatment to guide targeted therapy 2
• Pseudomonas UTIs are classified as complicated UTIs requiring targeted antimicrobial therapy due to intrinsic resistance patterns 2, 3
• Address any underlying urological abnormalities or complicating factors that may contribute to infection 2, 4

Treatment Options Based on Susceptibility

For Susceptible Pseudomonas aeruginosa:

• First-line options:
  • Ciprofloxacin 400 mg IV q8h or 750 mg PO daily (only if local resistance is <10%) 1, 5
  • Levofloxacin 750 mg IV/PO daily 1, 5
  • Piperacillin/tazobactam 3.375-4.5 g IV q6h 1, 3
  • Ceftazidime 2 g IV q8h 1, 6
  • Amikacin 15 mg/kg IV daily (for urinary tract infections only) 1, 7

For Difficult-to-Treat Resistant Pseudomonas aeruginosa (DTR-PA):

• Preferred options:
  • Ceftolozane/tazobactam 1.5-3 g IV q8h 1, 2
  • Ceftazidime/avibactam 2.5 g IV q8h 1, 2
  • Colistin monotherapy or combination therapy 1, 3
  • Imipenem/cilastatin/relebactam 1.25 g IV q6h 1, 3

Treatment Duration

• 7-14 days is the recommended treatment duration for Pseudomonas UTIs 2, 3
• For male patients where prostatitis cannot be excluded, extend treatment to 14 days 2, 4
• When the patient is hemodynamically stable and has been afebrile for at least 48 hours, a shorter treatment duration (7 days) may be considered 2, 4

Special Considerations

Catheterized Patients

• Consider catheter removal or replacement if clinically appropriate 2, 8
• Patients with indwelling catheters have a higher risk of developing febrile infections (66.7% vs 40.5% in non-catheterized patients) 8

Fluoroquinolone Use

• Only use ciprofloxacin when:
  • Local resistance rate is <10% 2, 6
  • The patient does not require hospitalization 2
  • The patient has not used fluoroquinolones in the last 6 months 2, 4
  • The patient has anaphylaxis to β-lactam antimicrobials 2

Common Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria as this increases the risk of developing resistant strains 2, 1
• Avoid prolonged courses of antibiotics beyond what is necessary, as this contributes to resistance development 2, 6
• Do not rely on fluoroquinolones as first-line agents due to increasing resistance patterns 2, 6
• Avoid classifying patients with recurrent UTIs as "complicated" as this often leads to use of broad-spectrum antibiotics with long durations of treatment 1

Monitoring and Follow-up

• Adjust therapy based on culture results once available 2, 3
• For persistent symptoms despite treatment, repeat urine culture to assess for ongoing bacteriuria before prescribing additional antibiotics 1
• Monitor for resolution of symptoms and consider follow-up urine culture in complicated cases 4