What antibiotic (ABx) is given for pyuria?

Antibiotic Treatment for Pyuria

For pyuria, first-line antibiotic treatment options include nitrofurantoin, fosfomycin, or trimethoprim-sulfamethoxazole, with the choice depending on suspected infection location and patient factors. 1

Understanding Pyuria and Treatment Approach

Pyuria refers to the presence of white blood cells in urine and is commonly associated with urinary tract infections (UTIs). Treatment depends on:

• Location of infection (lower vs. upper UTI)
• Patient characteristics (gender, pregnancy status)
• Local resistance patterns

Lower Urinary Tract Infection (Uncomplicated Cystitis)

First-line options:

• Nitrofurantoin macrocrystals: 50-100 mg four times daily or 100 mg twice daily for 5 days 1
• Fosfomycin trometamol: 3 g single dose (recommended only for uncomplicated cystitis in women) 1
• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days (avoid in first trimester of pregnancy) 1

Alternative options:

• Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) if local E. coli resistance is <20% 1
• Pivmecillinam: 400 mg three times daily for 3-5 days 1
• Amoxicillin-clavulanate: Effective but associated with more adverse effects than first-line options 1, 2

Upper Urinary Tract Infection (Pyelonephritis)

Oral treatment (mild to moderate cases):

• Ciprofloxacin: 500-750 mg twice daily for 7 days 1
• Levofloxacin: 750 mg once daily for 5 days 1
• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 14 days (only if pathogen is known to be susceptible) 1

Intravenous treatment (severe cases requiring hospitalization):

• Ceftriaxone: 1-2 g once daily 1
• Ciprofloxacin: 400 mg twice daily 1
• Amikacin: 15 mg/kg once daily 1

Special Considerations

Gender-specific recommendations:

• Men: Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days; fluoroquinolones can be prescribed based on local susceptibility testing 1
• Women: Shorter treatment durations are effective (3-5 days for most antibiotics) 1

Pregnancy:

• Avoid trimethoprim in first trimester 1
• Avoid trimethoprim-sulfamethoxazole in last trimester 1
• Fosfomycin trometamol single dose is recommended for asymptomatic bacteriuria in pregnancy 1

Recurrent UTIs:

• Obtain urine culture before starting treatment 1
• Consider non-antimicrobial interventions before antimicrobial prophylaxis 1
• For patients with good compliance, self-administered short-term antimicrobial therapy can be considered 1

Important Clinical Pearls

• Always obtain a urine culture in cases of suspected pyelonephritis before starting antibiotics 1
• Fluoroquinolones should be reserved for more invasive infections due to their propensity for collateral damage and adverse effects 1, 3
• Beta-lactams generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials 1
• Amoxicillin or ampicillin should not be used for empirical treatment due to poor efficacy and high resistance rates 1
• Pyuria typically regresses by ≥65% within a few days of appropriate antibiotic therapy 4

Antibiotic Selection Algorithm

1. Determine infection location: Lower UTI (cystitis) vs. Upper UTI (pyelonephritis)
2. Consider patient factors: Gender, pregnancy status, renal function
3. Review local resistance patterns: Especially for E. coli (most common pathogen)
4. Select appropriate antibiotic:
   • For uncomplicated cystitis: Nitrofurantoin, fosfomycin, or TMP-SMX
   • For pyelonephritis: Fluoroquinolones or TMP-SMX (if susceptible)
5. Adjust based on culture results when available 1