Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
The following is a summary of the recommendations for complicated urinary tract infections due to urological disorders. Refer to the original guideline for more detailed recommendations and discussion.
Levels of evidence (Ia-IV) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
A complicated urinary tract infection (UTI) is an infection associated with a condition, such as a structural or functional abnormality of the genitourinary tract, or the presence of an underlying disease that interferes with host defence mechanisms, which increase the risks of acquiring infection or of failing therapy.
A broad range of bacteria can cause a complicated UTI. The spectrum is much larger than in uncomplicated UTIs and bacteria are more likely to be resistant to antimicrobials, especially in a treatment-related complicated UTI.
Enterobacteriaceae are the predominant pathogens, with Escherichia coli being the most common pathogen. However, non-fermenters (e.g., Pseudomonas aeruginosa) and Gram-positive cocci (e.g., staphylococci and enterococci) may also play an important role, depending on the underlying conditions.
Treatment strategy depends on the severity of the illness. Treatment encompasses three goals: management of the urological abnormality, antimicrobial therapy (see table below), and supportive care when needed. Hospitalization is often required. To avoid the emergence of resistant strains, therapy should be guided by urine culture whenever possible.
If empirical therapy is necessary, the antibacterial spectrum of the antibiotic agent should include the most relevant pathogens (A). A fluoroquinolone with mainly renal excretion, an aminopenicillin plus a beta-lactam inhibitor (BLI), a Group 2 or 3a cephalosporin or, in the case of parenteral therapy, an aminoglycoside, are recommended alternatives (1bB).
In case of failure of initial therapy, or in case of clinically severe infection, a broader-spectrum antibiotic should be chosen that is also active against Pseudomonas (1bB) (e.g., a fluoroquinolone [if not used for initial therapy], an acylaminopenicillin [piperacillin] plus a BLI, a Group 3b cephalosporin, or a carbapenem, with or without combination with an aminoglycoside) (1bB).
The duration of therapy is usually 7-14 days (1bA), but has sometimes to be prolonged for up to 21 days (1bA).
Until predisposing factors are completely removed, true cure without recurrent infection is usually not possible. Therefore, a urine culture should be carried out 5−9 days after the completion of therapy and also 4−6 weeks later (B).
Table: Antimicrobial Treatment Options for Empiric Therapy
Antibiotics Recommended for Initial Empirical Treatment
- Fluoroquinolones
- Aminopenicillin plus a BLI
- Cephalosporin (Groups 2 or 3a)
- Aminoglycoside
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Antibiotics Recommended for Empirical Treatment in Case of Initial Failure or for Severe Cases
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Antibiotics Not Recommended for Empirical Treatment
- Aminopenicillins (e.g., amoxicillin, ampicillin)
- Trimethoprim-sulphamethoxazole (only if susceptibility of pathogen is known)
- Fosfomycin trometamol
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BLI = beta-lactam inhibitor
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Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis of randomized trials
Ib Evidence obtained from at least one randomized trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study
III Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
IV Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
