What is the treatment for a urinary tract infection (UTI) with hematuria?

Treatment for UTI with Hematuria

For a urinary tract infection presenting with hematuria, treat according to whether the infection is uncomplicated or complicated, using first-line agents (nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin) for uncomplicated cases in women, or combination therapy with amoxicillin plus aminoglycoside or third-generation cephalosporin for complicated cases, with treatment duration of 7-14 days. 1

Key Clinical Context

Hematuria is explicitly recognized as a symptom compatible with catheter-associated UTI and complicated UTI, particularly when acute in onset 1. The presence of hematuria does not fundamentally change antibiotic selection but may indicate a more severe or complicated infection requiring careful evaluation.

Treatment Approach Based on Clinical Scenario

For Uncomplicated UTI with Hematuria (Otherwise Healthy Women)

• First-line empiric therapy should be nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, selected based on local antibiogram 1
• Treatment duration: 7 days maximum, with shorter courses preferred when reasonable 1
• Obtain urine culture prior to initiating treatment to guide therapy adjustment 1
• Avoid fluoroquinolones as first-line due to resistance concerns and collateral damage, unless local resistance to first-line agents exceeds 10% 1

For Complicated UTI with Hematuria (Males, Catheterized Patients, Structural Abnormalities)

Empiric combination therapy is strongly recommended 1:

• Amoxicillin plus aminoglycoside, OR
• Second-generation cephalosporin plus aminoglycoside, OR
• Intravenous third-generation cephalosporin for patients with systemic symptoms 1

Treatment duration: 7-14 days (14 days for men when prostatitis cannot be excluded) 1

Ciprofloxacin restrictions: Only use if local resistance <10% AND patient doesn't require hospitalization AND no fluoroquinolone use in past 6 months 1

For Catheter-Associated UTI with Hematuria

• Remove or replace catheter as soon as clinically appropriate 1
• Treat as complicated UTI using combination therapy outlined above 1
• Standard duration: 7-14 days regardless of whether catheter remains 1
• Alternative for mild CA-UTI: Levofloxacin 750 mg daily for 5 days may be considered in non-severely ill patients 1
• Shorter course exception: 3-day regimen reasonable for women ≤65 years without upper tract symptoms after catheter removal 1

Critical Management Principles

Mandatory Actions

• Obtain urine culture and sensitivity before initiating antibiotics in all complicated cases 1
• Address underlying abnormalities: Any urological obstruction, foreign body, or structural issue must be managed concurrently 1
• Tailor therapy based on culture results and adjust from empiric to targeted treatment 1

Duration Considerations

Shorter treatment (7 days) may be considered when 1:

• Patient hemodynamically stable
• Afebrile for ≥48 hours
• Relative contraindications to prolonged antibiotic use exist

Extend treatment and consider urologic evaluation if 1:

• No clinical response with defervescence by 72 hours
• Persistent symptoms despite appropriate therapy

Special Populations and Resistance Patterns

For Multidrug-Resistant Organisms

If ESBL-producing Enterobacterales 1:

• Ceftazidime-avibactam 2.5 g IV q8h
• Meropenem-vaborbactam 4 g IV q8h
• Imipenem-cilastatin-relebactam 1.25 g IV q6h
• Single-dose aminoglycoside for simple cystitis due to CRE

High-dose amoxicillin-clavulanate (2875 mg amoxicillin/125 mg clavulanic acid twice daily) may break ESBL resistance in select outpatient cases 2

Pediatric Considerations (Ages 2-24 Months)

• Oral options: Cephalosporin, amoxicillin-clavulanate, or TMP-SMX based on local susceptibility 1
• Avoid nitrofurantoin in febrile infants as it doesn't achieve adequate parenchymal concentrations 1
• Duration: 7-14 days total therapy 1

Common Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria even with hematuria present, unless patient is pregnant or undergoing urologic procedures 1
• Avoid single-dose therapy for complicated UTI or when hematuria suggests upper tract involvement 1
• Do not use fluoroquinolones empirically in urology department patients or those with recent fluoroquinolone exposure 1
• Do not ignore local resistance patterns: TMP-SMX and ciprofloxacin resistance may preclude their use in many communities 3