Empiric Antibiotic Treatment for UTI After TURP
For a urinary tract infection following transurethral resection of the prostate (TURP), initiate empiric therapy with intravenous ceftriaxone 2 g once daily or cefepime 2 g every 12 hours, then transition to oral ciprofloxacin 500–750 mg twice daily or levofloxacin 750 mg once daily for a total duration of 14 days, as all UTIs in males are complicated and prostatitis cannot be excluded after TURP. 1, 2
Initial Empiric Parenteral Therapy
Start with ceftriaxone 2 g IV/IM once daily as first-line empiric therapy because it provides excellent urinary concentrations, broad-spectrum coverage against common post-TURP uropathogens (E. coli, Proteus, Klebsiella), and avoids nephrotoxicity while awaiting culture results. 1
Cefepime 2 g IV every 12 hours is an appropriate alternative when Pseudomonas aeruginosa coverage is needed, particularly in patients with recent healthcare exposure or prior fluoroquinolone use. 1
Avoid aminoglycosides (gentamicin, amikacin) in patients with unknown or impaired renal function until creatinine clearance is calculated, as these agents are highly nephrotoxic and require precise weight-based dosing. 1
Addressing Fluoroquinolone Allergy
If the patient has a documented fluoroquinolone allergy, continue parenteral therapy with ceftriaxone or cefepime for 3–5 days until clinically stable (afebrile ≥48 hours, hemodynamically stable), then transition to trimethoprim-sulfamethoxazole 160/800 mg orally twice daily for 14 days if the organism is susceptible. 1
Oral cephalosporins (cefpodoxime 200 mg twice daily, ceftibuten 400 mg once daily) for 10–14 days are acceptable alternatives when fluoroquinolones and trimethoprim-sulfamethoxazole cannot be used, though they have 15–30% higher failure rates. 1
Renal Impairment Considerations
For patients with stage 3–4 CKD (eGFR 15–59 mL/min), use ceftriaxone 1–2 g once daily without dose adjustment, as it does not require renal modification until eGFR <15 mL/min. 1
If using cefepime in advanced CKD (stage 4, eGFR 15–29 mL/min), reduce the dose to 1 g IV every 24 hours to prevent neurotoxicity (confusion, tremor, seizures), which occurs frequently even with dose adjustment. 1
Levofloxacin dosing for CrCl 20–49 mL/min requires a 750 mg loading dose followed by 250 mg every 48 hours; the standard 750 mg daily dose causes drug accumulation and increased toxicity risk in elderly patients with CKD. 1
Trimethoprim-sulfamethoxazole for CrCl 15–30 mL/min should be dosed as one double-strength tablet (160/800 mg) once daily (half the usual dose) to prevent accumulation. 1
Oral Step-Down Therapy
Transition to oral therapy once the patient is afebrile for ≥48 hours, hemodynamically stable, and culture results are available. 1
Ciprofloxacin 500–750 mg orally twice daily for 14 days is the preferred oral step-down when the isolate is susceptible and local fluoroquinolone resistance is <10%. 1, 2
Levofloxacin 750 mg orally once daily for 14 days provides equivalent efficacy to ciprofloxacin when susceptibility is confirmed and local resistance remains <10%. 1, 2
Reserve fluoroquinolones only when local resistance is <10% and the patient has had no fluoroquinolone exposure in the preceding 3 months, as empiric use in high-resistance settings leads to treatment failure. 1, 2
Treatment Duration Rationale
All UTIs in males require 14 days of therapy because prostatitis cannot be definitively excluded after TURP, and shorter courses are associated with higher relapse rates. 1, 2
A 7-day course is insufficient for post-TURP UTI even when symptoms resolve promptly, as prostatic involvement is common and requires extended treatment to prevent recurrence. 2
The 5-day levofloxacin 750 mg regimen recommended for uncomplicated pyelonephritis in women does not apply to males, whose UTIs are categorically complicated. 2
Local Resistance Pattern Assessment
Obtain urine culture with susceptibility testing before initiating antibiotics to enable targeted therapy, as post-TURP infections have a broader microbial spectrum and higher resistance rates than community-acquired UTIs. 1, 2
Evaluate local antibiogram data for fluoroquinolone resistance rates before selecting empiric oral therapy; if local E. coli resistance exceeds 10%, choose an alternative agent based on susceptibility patterns. 1, 2
Patients with preoperative indwelling catheters have higher rates of multidrug-resistant organisms, including ESBL-producing Enterobacteriaceae, necessitating broader empiric coverage. 3, 4
Special Post-TURP Considerations
Patients with preoperative urinary retention and indwelling catheters have a 26% incidence of early infectious complications despite prophylaxis, requiring vigilant monitoring and prompt treatment. 5
Gram-positive organisms (particularly Enterococcus) are increasingly responsible for post-TURP infections, especially in patients who received perioperative prophylaxis with gram-negative-only coverage. 4
If fever persists beyond 72 hours despite appropriate antibiotic therapy, obtain imaging (ultrasound or CT) to exclude prostatic abscess, urinary obstruction, or retained prostatic tissue. 1
Critical Pitfalls to Avoid
Do not use nitrofurantoin or fosfomycin for post-TURP UTI, as these agents have insufficient tissue penetration for prostatic infections and lack efficacy data for complicated UTIs. 1
Do not apply the 7-day duration recommended for uncomplicated pyelonephritis in women to male patients, as this leads to higher microbiologic failure rates. 2
Do not use empiric fluoroquinolones when local resistance exceeds 10% or the patient has recent fluoroquinolone exposure, as this significantly increases treatment failure risk. 1, 2
Do not omit urine culture before initiating therapy, as post-TURP infections often involve resistant organisms requiring targeted treatment. 1, 2
Do not use moxifloxacin for any urinary tract infection, as its urinary concentrations are uncertain and may be ineffective. 1