From the Guidelines
For adults with complicated urinary tract infections (UTIs), I recommend empiric therapy with an intravenous third-generation cephalosporin as the initial treatment, especially in patients with systemic symptoms, as suggested by the European Association of Urology guidelines 1. This approach is supported by the most recent guidelines, which emphasize the importance of managing any urological abnormality and/or underlying complicating factors, and using appropriate antimicrobial therapy based on the severity of the illness and local resistance patterns 1. Key considerations in the management of complicated UTIs include:
- The use of a combination of antibiotics, such as amoxicillin plus an aminoglycoside or a second-generation cephalosporin plus an aminoglycoside, as recommended by the European Association of Urology guidelines 1
- The avoidance of ciprofloxacin and other fluoroquinolones for empirical treatment in patients from urology departments or those who have used fluoroquinolones in the last 6 months, due to the high risk of resistance 1
- The importance of adjusting treatment based on culture results when available, and managing any underlying complicating factors, such as urinary obstruction or immunosuppression 1
- The need for individualized treatment duration, which may range from 7 to 14 days, depending on the severity of the infection and the patient's response to treatment 1 Overall, the management of complicated UTIs requires a comprehensive approach that takes into account the patient's underlying health status, the severity of the infection, and the local antimicrobial resistance patterns, as emphasized by the European Association of Urology guidelines 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Complicated UTI Treatment Options
- The treatment of complicated urinary tract infections (cUTIs) can be challenging due to the increasing prevalence of antimicrobial resistance 2, 3, 4.
- Effective management requires prompt, targeted interventions based on local resistance profiles, patient-specific factors, and pharmacokinetic/pharmacodynamic considerations 3.
- Current evidence underscores the need for antimicrobial stewardship, precise diagnostics, and innovative therapies to address cUTIs while mitigating antimicrobial resistance 3.
Antibiotic Therapy
- Fluoroquinolones, trimethoprim-sulfamethoxazole, and nitrofurantoin are still appropriate empiric options for mild lower cUTIs, but should not be used as first-line options for serious cUTIs, especially when patients exhibit risk factors for harboring a resistant organism 4.
- Broad-spectrum antibiotics such as carbapenems or piperacillin-tazobactam should be used as empiric treatment for serious cUTIs, where risk factors for resistant organisms exist 4.
- Ceftriaxone therapy should be considered carefully in patients with complicated UTIs due to the possibility of enterococcal re-infection and consequent prolonged hospital stay 5.
Patient-Specific Factors
- Patients presenting with a suspected UTI should be screened for the presence of complicating factors, such as anatomic and functional abnormalities of the genitourinary tract 4.
- Consideration of an optimal antimicrobial agent should be based on local resistance patterns, patient-specific factors, including anatomic site of infection and severity of disease, pharmacokinetic and pharmacodynamic principles, and cost 4.
- Patients with chronic diseases and urinary catheter insertion are at higher risk of enterococcal re-infections 5.
Duration of Treatment
- The duration of treatment for cUTIs has not been well established, but treatment durations can range from 1 to 4 weeks based on the clinical situation 4.