What is the recommended treatment for a hospitalized patient with a urinary tract infection (UTI)?

Treatment of UTI in Hospitalized Patients

For hospitalized patients with complicated UTI and systemic symptoms, initiate empiric intravenous therapy with either a combination of amoxicillin plus an aminoglycoside, a second-generation cephalosporin plus an aminoglycoside, or an intravenous third-generation cephalosporin, then tailor therapy based on culture results and continue for 7-14 days. 1

Initial Assessment and Classification

Before initiating treatment, determine whether the UTI is complicated or uncomplicated:

• Complicated UTI includes patients with: obstruction, foreign bodies (catheters), incomplete voiding, male gender, pregnancy, diabetes, immunosuppression, healthcare-associated infections, recent instrumentation, or multidrug-resistant organisms 1
• Obtain urine culture and susceptibility testing prior to initiating treatment in all hospitalized patients 1
• Blood cultures should be obtained if sepsis is suspected or in severe cases 1

Empiric Antibiotic Selection

For Complicated UTI with Systemic Symptoms (Strong Recommendation)

The European Association of Urology 2024 guidelines provide clear first-line options 1:

Combination therapy options:

• Amoxicillin plus aminoglycoside (gentamicin 5 mg/kg daily or amikacin 15 mg/kg daily) 1
• Second-generation cephalosporin plus aminoglycoside 1
• Third-generation cephalosporin monotherapy: ceftriaxone 1-2g daily or cefotaxime 2g three times daily 1

Alternative parenteral options include:

• Piperacillin/tazobactam 2.5-4.5g three times daily 1
• Cefepime 1-2g twice daily 1

Fluoroquinolone Restrictions (Strong Recommendation)

Avoid ciprofloxacin and fluoroquinolones for empiric treatment in hospitalized patients unless 1:

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

The increasing resistance rates make fluoroquinolones inappropriate for serious hospitalized UTI cases 2, 3, 4

Special Considerations

Catheter-Associated UTI

• CA-UTI carries approximately 10% mortality risk and accounts for 20% of hospital-acquired bacteremias 1
• Use the same empiric regimens as complicated UTI 1
• Remove or replace the catheter when feasible 1

Multidrug-Resistant Organisms

For suspected or confirmed carbapenem-resistant Enterobacterales (CRE): 1

• Ceftazidime/avibactam 2.5g IV every 8 hours
• Meropenem/vaborbactam 4g IV every 8 hours
• Imipenem/cilastatin/relebactam 1.25g IV every 6 hours

Reserve carbapenems and novel broad-spectrum agents only for patients with early culture results indicating multidrug-resistant organisms 1

Pyelonephritis Requiring Hospitalization

For uncomplicated pyelonephritis requiring admission 1:

• Fluoroquinolones: ciprofloxacin 400mg twice daily or levofloxacin 750mg daily (only if local resistance <10%)
• Aminoglycosides with or without ampicillin
• Extended-spectrum cephalosporins or penicillins
• Gentamicin 5 mg/kg daily or amikacin 15 mg/kg daily

Treatment Duration

• Standard duration: 7-14 days for complicated UTI 1
• 14 days for men when prostatitis cannot be excluded 1
• Shorter duration (7 days) may be considered when patient is hemodynamically stable and afebrile for at least 48 hours 1
• Duration should be closely related to treatment of underlying abnormality 1

Transition to Oral Therapy

Once the patient is clinically stable (afebrile for 24-48 hours, hemodynamically stable, able to tolerate oral intake) 1:

• Tailor therapy based on culture and susceptibility results 1
• Oral options include: fluoroquinolones (if susceptible and local resistance <10%), cephalosporins, or amoxicillin-clavulanate 1

Critical Pitfalls to Avoid

• Do not use nitrofurantoin or fosfomycin for hospitalized patients with systemic symptoms—these agents do not achieve adequate blood levels 1, 4
• Do not treat asymptomatic bacteriuria in hospitalized patients (except pregnant women or those undergoing urologic procedures) 1
• Do not use fluoroquinolones empirically in urology departments or healthcare-associated infections due to high resistance rates 1
• Always address underlying urological abnormalities—antimicrobial therapy alone is insufficient without source control 1