What is the treatment for infectious ureteritis?

Treatment of Infectious Ureteritis

Infectious ureteritis should be treated as a complicated urinary tract infection with empirical broad-spectrum antimicrobials guided by culture results, combined with management of any underlying anatomical abnormalities or obstructions.

Initial Diagnostic Approach

Infectious ureteritis is rarely a primary infection and typically occurs secondary to ascending infection from cystitis, descending infection from pyelonephritis, or direct spread from adjacent inflammatory lesions 1. The condition should be approached as a complicated UTI given the involvement of the upper urinary tract structures 2.

Essential Diagnostic Steps

• Obtain urine culture and antimicrobial susceptibility testing before initiating therapy - this is mandatory for all upper urinary tract infections 2
• Perform imaging with ultrasound or contrast-enhanced CT to identify:
  • Urinary tract obstruction 2
  • Anatomical abnormalities (strictures, megaloureter, ureterocele) that predispose to ureteritis 1
  • Associated complications such as abscesses 2
• Assess for systemic involvement using SOFA or qSOFA scores if sepsis is suspected 2

Empirical Antimicrobial Therapy

For Hospitalized Patients or Severe Disease

Initiate intravenous broad-spectrum antimicrobials immediately while awaiting culture results 2:

First-line options:

• Fluoroquinolones: Ciprofloxacin 400 mg IV twice daily OR Levofloxacin 750 mg IV daily 2
• Extended-spectrum cephalosporins: Ceftriaxone 1-2 g IV daily OR Cefepime 1-2 g IV twice daily 2
• Beta-lactam/beta-lactamase inhibitors: Piperacillin/tazobactam 2.5-4.5 g IV three times daily 2
• Aminoglycosides: Gentamicin 5 mg/kg IV daily OR Amikacin 15 mg/kg IV daily (with or without ampicillin) 2

Reserve carbapenems and novel agents (meropenem, ceftolozane/tazobactam, ceftazidime/avibactam) only for patients with early culture results indicating multidrug-resistant organisms 2.

For Outpatient Management (Mild Cases)

If the patient is stable without systemic symptoms, oral therapy may be considered 2:

• Ciprofloxacin 500-750 mg orally twice daily for 7 days 2
• Levofloxacin 750 mg orally daily for 5 days 2

Source Control and Anatomical Management

This is critical and often determines treatment success 1:

• Relieve any urinary tract obstruction immediately - this is essential for preventing progression to urosepsis 2
• Drain significant abscesses within the urinary tract 2
• Consider ureteral stenting for cases with stricture formation to preserve renal function 1
• Address underlying predisposing factors: treat associated cystitis, pyelonephritis, remove calculi 1

Special Considerations

Duration of Therapy

• Treat for 7-14 days depending on clinical response and severity 1
• Adjust based on culture results and local resistance patterns 2

Monitoring and Follow-up

• If fever persists after 72 hours of appropriate therapy, obtain contrast-enhanced CT or excretory urography immediately 2
• If clinical deterioration occurs, perform imaging immediately and reassess for complications 2

Chronic or Recurrent Cases

For chronic ureteritis with stricture formation 1:

• Ureteral dilation or surgical excision of stenosed portions may be required 1
• Long-term ureteral stenting may be necessary to maintain patency and preserve renal function 1

Common Pitfalls to Avoid

• Do not treat ureteritis without addressing underlying anatomical abnormalities - the infection will recur 1
• Do not delay imaging in patients who remain febrile or deteriorate clinically 2
• Do not use nitrofurantoin, oral fosfomycin, or pivmecillinam for upper urinary tract infections - insufficient efficacy data 2
• Do not overlook the need for source control - antimicrobials alone are insufficient if obstruction or abscess is present 2

Multidisciplinary Approach

Collaborative treatment involving urologists, infectious disease specialists, and intensive care (if septic) is recommended for optimal outcomes 2.