What is the appropriate treatment and management plan for a patient with a urinary tract infection (UTI) caused by E. coli, presenting with hematuria, who has been prescribed antibiotics?

Management of E. coli UTI with Hematuria

For a patient with E. coli UTI presenting with hematuria, treat with 7 days of antibiotics tailored to culture susceptibilities, obtain urine culture before starting therapy, and assess for complicating factors that would classify this as a complicated UTI requiring broader empiric coverage. 1

Initial Diagnostic Approach

• Obtain urine culture and susceptibility testing before initiating antibiotics to guide definitive therapy, particularly given the wide spectrum of potential organisms and increased likelihood of antimicrobial resistance in complicated UTIs 1
• Assess for complicating factors including male gender, recent instrumentation, catheter use, diabetes, immunosuppression, urinary obstruction, or incomplete voiding—any of which would classify this as a complicated UTI 1
• Hematuria itself warrants consideration as a complicating feature, particularly if acute in onset 1

Empiric Antibiotic Selection

The choice depends critically on whether this is complicated or uncomplicated:

If Complicated UTI (presence of complicating factors):

Use combination therapy with systemic symptoms: 1

• Amoxicillin plus aminoglycoside, OR
• Second-generation cephalosporin plus aminoglycoside, OR
• Intravenous third-generation cephalosporin (ceftriaxone 1-2g daily or cefotaxime 2g three times daily) 1

Ciprofloxacin should only be used if: 1

• Local resistance rate is <10%, AND
• Patient has not used fluoroquinolones in the last 6 months, AND
• Patient is not from a urology department

Important caveat: The FDA issued warnings that fluoroquinolones should not be used for uncomplicated UTIs due to unfavorable risk-benefit ratios from disabling adverse effects 1. Even for complicated cases, fluoroquinolones are increasingly problematic due to rising resistance rates and collateral damage to protective microbiota 1.

If Uncomplicated (no complicating factors, which is less likely with hematuria):

First-line options include: 1

• Nitrofurantoin 100mg twice daily for 5 days
• Fosfomycin 3g single dose
• Pivmecillinam 400mg three times daily for 3-5 days

Treatment Duration

7 days is the recommended duration for most patients with complicated UTI who have prompt symptom resolution 1

10-14 days is recommended for: 1

• Patients with delayed clinical response (no defervescence by 72 hours)
• Men when prostatitis cannot be excluded 1

Shorter courses (5 days of levofloxacin) may be considered only if: 1

• Patient is not severely ill
• This is catheter-associated UTI with mild symptoms

Catheter Management (if applicable)

If an indwelling catheter has been in place ≥2 weeks: 1

• Replace the catheter before initiating antimicrobial therapy to hasten symptom resolution and reduce risk of subsequent bacteriuria
• Obtain urine culture from the freshly placed catheter prior to starting antibiotics 1

Remove the catheter as soon as clinically appropriate regardless of infection status 1

Adjusting Therapy Based on Culture Results

• Tailor antibiotic selection once susceptibilities are available rather than continuing empiric broad-spectrum coverage 1
• Switch to oral therapy when the patient is hemodynamically stable and afebrile for at least 48 hours 1
• Consider extending treatment and performing urologic evaluation if the patient does not show clinical response with defervescence by 72 hours 1

Common Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria—this increases risk of symptomatic infection, bacterial resistance, and healthcare costs 1
• Avoid nitrofurantoin for febrile UTI or pyelonephritis—it does not achieve adequate parenchymal or serum concentrations 1
• Do not use moxifloxacin for UTI—uncertainty exists regarding effective urinary concentrations 1
• Avoid fluoroquinolones and cephalosporins when possible—they cause more collateral damage to protective microbiota and promote C. difficile infection compared to other antibiotic classes 1
• Do not assume uncomplicated UTI in the presence of hematuria—this warrants careful evaluation for complicating factors 1

Resistance Considerations

• E. coli resistance patterns vary significantly by geography and patient population 1
• Trimethoprim-sulfamethoxazole resistance exceeds 15% in many communities, particularly for recurrent UTIs (19.3-21.4% resistance) 2
• Fluoroquinolone resistance is increasing, with some cohorts showing 83.8% persistent ciprofloxacin resistance 1
• First-line agents (nitrofurantoin, fosfomycin, pivmecillinam) maintain favorable resistance profiles with <15% resistance even in recurrent UTIs 2