eMedicine Specialties > Infectious Diseases > Genitourinary Tract Infections

Urinary Tract Infection, Females: Treatment & Medication

Author: Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Coauthor(s): Jeffrey M Tessier, MD, Assistant Professor, Department of Medicine, Uniformed Services University of the Health Sciences; Mary F Bavaro, MD, Chief, Division of Infectious Disease, Navy Medical Center, San Diego
Contributor Information and Disclosures

Updated: Oct 19, 2009

Treatment

Medical Care

For adult women with acute bacterial cystitis who are otherwise healthy and not pregnant, single-dose therapy generally is less effective than a longer duration of the same antimicrobial agent. Most antimicrobial agents administered for 3 days are as effective as the same drug administered for a longer duration, with exceptions being nitrofurantoin and beta-lactams as a group.

TMP-SMZ for 3 days is considered the current standard therapy for bacterial cystitis. TMP-SMZ works as well as fluoroquinolones, which are more expensive. In 1999, to postpone the emergence of quinolone resistance, IDSA guidelines for urinary tract infection (UTI) did not recommend quinolones as initial empiric therapy, except in communities with high rates (ie, over 10-20%) of uropathogen resistance to TMP-SMZ. Quinolones should be used for patients with known TMP-SMZ allergies, known TMP-SMZ–resistant pathogens, or those failing a TMP-SMZ regimen.

Drug selection could be facilitated if resistance patterns among uropathogens could be predicted clinically. Studies have compared women with UTI caused by TMP-resistant bacteria with women with TMP-sensitive isolates. After multivariate analysis, the strongest risk factor was current or recent use of TMP-SMZ; current use of any antibiotic, estrogen exposure, diabetes, and recent hospitalization also were significant. Rates of fecal colonization with TMP-SMZ–resistant E coli are increased in those who have recently been to Mexico, children in daycare centers, and in family members of those recently treated for a UTI.

  • Cystitis
    • Cystitis in older women or infection caused by S saprophyticus is less responsive to 3 days of therapy; therefore, 7 days of therapy is suggested.
    • Bladder analgesia using phenazopyridine 200 mg tid should be considered in women with severe dysuria. Duration of therapy should be limited to 2 or 3 days to ensure clinical improvement of symptoms.
  • Pyelonephritis
    • Fewer firm data are available on which to base sound treatment recommendations for pyelonephritis. For young women who are not pregnant with normal urinary tracts, 14 days of therapy is appropriate.
    • Mild infections can be managed with oral fluoroquinolones or TMP-SMZ. Women who should be considered for outpatient treatment include those with mild-to-moderate infection, those with easy access to follow-up appointments, and women without significant nausea or vomiting.
    • Patients presenting with acute pyelonephritis can be treated with a single dose of a parenteral antibiotic followed by oral therapy, provided they are monitored within the first 48 h. A study of febrile, nonpregnant women presenting with symptoms of acute pyelonephritis found that 25% were hospitalized. These patients tended to be older and have diabetes, higher temperatures, and vomiting. Eighty percent of the outpatients were treated with a single parenteral dose of ceftriaxone or gentamicin, followed by oral therapy (usually TMP-SMZ). Twelve percent returned with persistent symptoms, most in the first day; most of these were admitted.
    • Hospitalize patients with more severe infection and treat with a parenteral fluoroquinolone, an aminoglycoside (with or without ampicillin), or an extended-spectrum cephalosporin (with or without an aminoglycoside). Treat gram-positive cocci with ampicillin/sulbactam (with or without an aminoglycoside).
    • Patients who relapse despite adequate therapy who lack anatomic abnormalities should be treated for 6 weeks. If a new pathogen causes infection, then another 2-week course should be effective.
  • Urinary tract infections associated with calculi
    • For UTIs associated with calculi, treatment ranges from observation to nephrectomy.
    • The preferred method of treatment is surgical (see Surgical Care). Mere observation is not recommended, as the mortality is 28% versus 7.2% in the surgically treated group. Antibiotic therapy should be used in conjunction.
    • Although food and vitamin supplements that are rich in phosphorus and magnesium are advisable, remember that magnesium (and other divalent cations) can chelate quinolones, preventing their absorption from the gut.
    • Acidifying agents have been used. Ascorbic acid does not significantly decrease urinary pH, and ammonium chloride provides only temporary acidification.
    • Urease inhibitors are effective in reducing stone formation, but long-term use is fraught with neurosensory, hematologic, and dermatologic adverse effects.
  • Renal carbuncles
    • For renal carbuncles, surgical drainage once was the only treatment. However, modern antibiotics alone often are curative. A semisynthetic penicillin, cephalosporin, quinolone, or vancomycin is recommended.
    • Generally, parenteral antibiotics should be administered for 10-14 days, followed by oral therapy for 2-4 weeks. Fever should resolve within 5-6 days and pain within 24 hours.
    • If patients do not respond within 48 hours, percutaneous (or open) drainage should be performed.
  • Acute, focal, and multifocal bacterial nephritis
    • Acute, focal, and multifocal bacterial nephritis should respond to antibiotics within 1 week. An extended-spectrum penicillin, cephalosporin, or quinolone should be used. A beta-lactam and an aminoglycoside also may be considered.
    • Parenteral therapy should be used first, followed by at least 2 weeks of oral therapy. Those with large abscesses (ie, >5 cm), obstructive uropathy, advanced age, and urosepsis may not respond to antimicrobial therapy alone and require percutaneous drainage.
    • Patients with severely damaged renal parenchyma, xanthogranulomatous pyelonephritis, or patients who are elderly and have sepsis may require nephrectomy.
  • Perinephric abscesses
    • Perinephric abscesses are associated with a high mortality rate (ie, 20-50%) and require percutaneous or surgical drainage and antibiotics.
    • An aminoglycoside and an antistaphylococcal penicillin should be used. An extended-spectrum beta-lactam also may be used.
    • Antibiotics should be modified based on culture results.
  • Spinal cord injury and urinary tract infections
    • Antibiotics should be reserved for patients with clear signs and symptoms of UTI.
    • Oral fluoroquinolones are the drugs of choice for empiric treatment of acute UTIs.
    • Options for hospitalized patients include parenteral fluoroquinolones, ampicillin and gentamicin, imipenem plus cilastatin, third-generation cephalosporins, beta-lactam/beta-lactamase inhibitor combinations, or the aminoglycosides.
    • Duration of therapy generally is 7-14 days, but 4-5 days may be acceptable for patients who are mildly symptomatic and who are closely monitored.
    • If a patient fails to respond, then another culture should be obtained and an imaging study should be considered to rule out persistent infection, stone disease, and anatomic abnormalities causing obstruction.
    • Treatment of asymptomatic patients is more controversial. While urine cultures with low bacterial counts often become sterile without treatment, some patients with ASB develop chronic infections secondary to bacterial biofilms. Some suggest that first episodes of ASB should be treated if significant bacteriuria (ie, more than 10,000 CFU/mL) is accompanied by pyuria (ie, more than 8-10 leukocytes/hpf).

Surgical Care

  • Urinary tract infections associated with infected calculi
    • Treatment ranges from observation to nephrectomy. Hydronephrosis is a concern (see Image 3).

      Bilateral hydronephrosis.

      Bilateral hydronephrosis.

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      Bilateral hydronephrosis.

      Bilateral hydronephrosis.

    • Surgical options include extracorporeal shock wave lithotripsy (ESWL), endoscopic methods, percutaneous methods, or open surgery.
    • Mere observation is not recommended; the mortality associated with observation is 28%, versus 7.2% in the surgically treated group. Appropriate antibiotic therapy should be used as well.

Consultations

A pharmacokinetics consultation is suggested when using aminoglycosides or vancomycin. Urologic consultation is essential in patients with complicated UTIs. Other consultations depend on the patient's underlying state of health and may include an obstetrician, gynecologist, endocrinologist, nephrologist, neurologist, and neurosurgeon. Infectious disease input is essential for unusual or resistant pathogens or hosts who are immunocompromised. Consultation with the patient's primary care provider is suggested.

Diet

  • Hydration to accentuate unidirectional clearance of bacteruria is recommended, especially if an obstruction was relieved recently. Drinking cranberry juice (10 oz/d) may offer some benefit and does not appear to be harmful. One recent study found less recurrence of UTIs in women who drank 50 mL of cranberry-lingonberry concentrate daily for 6 months. The mechanism of action of cranberry juice is not clear. It is bacteriostatic, an effect probably due to hippuric acid. Another mechanism may involve suppression of E coli fimbriae by proanthocyanidins (tannins). Ascorbic acid (vitamin C) does not cause significant urinary acidification.
  • For complicated UTIs associated with struvite calculi, foods and vitamin supplements rich in phosphorus and magnesium are advised.
  • Remember that divalent cations (eg, magnesium, iron, calcium, zinc) can chelate oral fluoroquinolones, preventing their absorption from the gut.

Activity

Please see Deterrence/Prevention for a discussion on sexual activities and recurrent UTIs in women.

Medication

The goals of pharmacotherapy are to eradicate the infection, reduce morbidity, and prevent complications.

Antibiotics

Empiric antimicrobial therapy should cover all likely pathogens in the context of this clinical setting. The prolonged or repeated use of antibiotics may result in fungal or bacterial overgrowth of nonsusceptible organisms, superinfections, or infections with Clostridium difficile.

Antibiotics sometimes are used in combination. Sometimes these combinations work against each other (ie, are antagonistic); examples would include beta-lactams (such as penicillin) and tetracyclines. Antagonism is defined as at least a 99% decrease in killing by the combination (when compared with the most active antimicrobial alone).

Synergism is when a combination of antibiotics has a significantly greater effect than would be expected from the sum of the separate drugs (ie, over a 99% increase in killing). Aminoglycosides and either beta-lactams or vancomycin are considered synergistic combinations. Because no single drug is considered bactericidal for enterococci, some might prefer to use synergistic combinations when treating enterococcal urinary tract infections (UTIs).

The techniques used to generate data regarding synergy and antagonism are laborious and should generally be performed only in a research laboratory.


Trimethoprim (Proloprim, Trimpex)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Active in vitro against a broad range of gram-positive and gram-negative bacteria, including uropathogens, such as Enterobacteriaceae and S saprophyticus. Resistance usually is mediated by decreased cell permeability or alterations in the amount or structure of dihydrofolate reductase. Demonstrates synergy with the sulfonamides, potentiating the inhibition of bacterial tetrahydrofolate production.

Adult

100-200 mg PO q12h

Pediatric

Not established

Increases effect of phenytoin and rifampin; impairs excretion of creatinine (when present with cyclosporine) and methotrexate

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue at first appearance of skin rash or sign of adverse reaction; monitor CBCs; discontinue therapy if significant hematologic changes occur; high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, patients with long-term alcoholism, elderly people, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in individuals who are G-6-PD deficient; caution in renal or hepatic impairment (perform urinalysis and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation; adverse effects include nausea, vomiting, hypersensitivity reactions with morbilliform rash (especially in patients with AIDS), and diarrhea; less common adverse effects include marrow suppression, renal dysfunction, hepatitis, and aseptic meningitis


Trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS, Cotrim)

TMP-SMZ has been given an "A, I" rating in the 1999 IDSA guidelines for treating UTIs. Combination antimicrobial designed to take advantage of the synergy between TMP and sulfonamides. Inhibits dihydropteroate synthetase, preventing the incorporation of para- aminobenzoic acid (PABA) into dihydrofolate and subsequent synthesis of tetrahydrofolate. TMP-SMZ activity includes common urinary tract pathogens, both aerobic gram-positive and gram-negative bacteria, except P aeruginosa.

Adult

Traditional dosing: 160 mg TMP/800 mg SMZ PO q12h for 10-14 d
Parenteral dose: 4-5 mg/kg TMP with 20-25 mg/kg SMZ PO q12h
Dosage adjustment is recommended for impaired CrCl (<30 mL/min)

Pediatric

8-12 mg/kg TMP component PO divided bid

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; coadministration with sulfonylureas may increase hypoglycemic response to sulfonylureas

Documented hypersensitivity; megaloblastic anemia due to folate deficiency; risk/benefit assessment should be considered in patients with G6PD deficiency, blood dyscrasias, folate deficiency, porphyria, hepatic or renal impairment

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue at first appearance of skin rash or sign of adverse reaction; monitor CBCs; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, people with long-term alcoholism, elderly people, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in individuals who are G-6-PD deficient; patients with AIDS may not tolerate or respond to TMP/SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation


Ampicillin (Omnipen, Principen, Totacillin, Polycillin)

Impairs cell wall synthesis in actively dividing bacteria; binds to and inhibits penicillin-binding proteins (PBPs).
Activity against anaerobes and gram-negative aerobes. Generally used in combination with an aminoglycoside for empiric or directed activity against E faecalis.
Beta-lactams, in general, have been given an "E, I" rating in the 1999 IDSA guidelines for treating UTIs. Beta-lactams are less effective because they are excreted rapidly in the urine and do little to alter the GI/GU reservoir of bacteria.

Adult

Ampicillin trihydrate: 500 mg PO q6h
Ampicillin: 150-200 mg/kg IV divided q4-6h (approximately 1g q6h)

Pediatric

<28 days: Not recommended
>28 days: 50 mg/kg PO/IV q6h

Decreased bioavailability of atenolol; altered response to coumarin derivatives; probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; avoid use in known infectious mononucleosis because a maculopapular rash will occur in >95% of cases and may be confused with hypersensitivity; not to be used alone for the treatment of UTIs because resistance is common; if used for cystitis, 7 d (not 3) must be prescribed


Amoxicillin (Trimox, Amoxil, Biomox)

Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.

Adult

250-500 mg PO q8h; not to exceed 3 g/d

Pediatric

20-50 mg/kg/d PO divided q8h

Reduces the efficacy of oral contraceptives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; may enhance chance of candidiasis


Gentamicin (Garamycin, Gentacidin)

Bactericidal aminoglycoside antibiotic that inhibits bacterial protein synthesis. Activity against various aerobic gram-negative bacteria, as well as E faecalis and staphylococcal species. Most commonly used with or without ampicillin to treat acute pyelonephritis in the hospitalized patient when Enterococcus species are a concern. Only aminoglycoside with appreciable activity against gram-positive organisms.
Requires dosing adjustment based on CrCl; IBW should be used for the calculation (the drug is not fat soluble). Trough serum levels should be monitored to ensure adequate clearance and reduce toxicity (<2 mcg/mL). Peak levels should also be monitored (may draw 0.5 h after 30-min infusion) after 4-5 half-lives when dosed more than once daily (levels should not exceed 12 mcg/mL for prolonged periods).
Daily dosing is not appropriate for treating gram-positive infections because the drug exhibits no appreciable postantibiotic effect with these organisms.

Adult

3-5 mg/kg IV qd
1 mg/kg IV q8h

Pediatric

<28 days: Not recommended
>28 days: 2.5 mg/kg IV q8h

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; irreversible CN 8 dysfunction may occur (monitoring may minimize)

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment


Cefixime (Suprax)

Third-generation oral cephalosporin with broad activity against gram-negative bacteria, including Enterobacteriaceae, by inhibiting cell wall synthesis. Has shown poor activity against staphylococcal and enterococcal species. Cefixime compared favorably to a quinolone in one study.

Adult

400 mg PO qd

Pediatric

8 mg/kg PO qd

Coadministration of aminoglycosides increases nephrotoxicity; probenecid may increase effects of cefixime; may decrease effectiveness of oral contraceptives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections, and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; may increase risk for C difficile infection; expensive but tolerated well by patients


Cefpodoxime proxetil (Vantin)

Extended-spectrum oral cephalosporin with bactericidal activity against gram-positive and gram-negative bacteria, including S aureus (not MRSA) and S saprophyticus. Active agent in vivo is cefpodoxime. Beta-lactams, in general, have been given an "E, I" rating in the 1999 IDSA guidelines for treating UTIs.

Adult

Acute cystitis: 100 mg PO q12h
Acute pyelonephritis: 200 mg PO q12h

Pediatric

10 mg/kg PO divided bid; not to exceed 400 mg/d

Decreased effect with antacids and H2-receptor antagonists; increased effect with probenecid

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy


Nitrofurantoin (Furadantin, Macrobid, Macrodantin)

Synthetic nitrofuran that interferes with bacterial carbohydrate metabolism by inhibiting acetylcoenzyme A. Bacteriostatic at low concentrations (5-10 mcg/mL) and bactericidal at higher concentrations. Bactericidal against uropathogens such as S saprophyticus, E faecalis, and E coli; possesses no activity against Proteus, Serratia, or Pseudomonas species. Received a "B, I" rating in the 1999 IDSA guidelines for treating UTIs. Manufactured in different forms to facilitate durable urine concentrations: macrocrystals (Macrodantin), microcrystal suspension (Furadantin), and a combined preparation (Macrobid). Achieves no appreciable concentrations in the prostate, kidney, or blood.

Adult

Nitrofurantoin monohydrate/macrocrystals (Macrobid): 100 mg PO bid
Nitrofurantoin macrocrystals (Macrodantin): 50-100 mg PO qid

Pediatric

Not established

Anticholinergics may delay gastric emptying and increase absorption, increasing bioavailability; antacids made of magnesium salts may decrease absorption; high doses of probenecid concurrently with nitrofurantoin decreases renal clearance; may decrease efficacy of quinolones

Documented hypersensitivity; renal insufficiency (<60 mL/min CrCl); anuria or oliguria; at term in pregnant women due to risk of acute hemolysis in newborn with G-6-PD deficiency (it can displace bilirubin)

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Nitrofurantoin may cause severe and irreversible peripheral neuropathy; renal impairment, diabetes, electrolyte imbalance, anemia, and vitamin B deficiency increase risk for adverse effects; pulmonary hypersensitivity syndromes (ie, acute, subacute, chronic) can occur and are more common in patients who have been sensitized to nitrofurantoin through prior use; acute reactions (eg, fever, dyspnea, eosinophilia, pulmonary infiltrates) usually occur in the first 12 h in sensitized patients or within 3 wk in newly exposed patients; subacute reactions occur after longer exposures (>1 mo), and chronic reactions occur after 6 mo; reactions usually resolve after discontinuation of the drug; treatment with steroids may be useful; chronic syndrome may result in permanent pulmonary dysfunction


Ciprofloxacin (Cipro)

Quinolone. Antimicrobial activity based on ability to inhibit bacterial DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Differences in chemical structure between quinolones have resulted in altered levels of activity against different bacteria. Ciprofloxacin has greatest antimicrobial activity against P aeruginosa. Altered chemistry structures result in toxicity differences as well. Quinolones have been given an "A, I" or "A, II" rating in the 1999 IDSA guidelines for treating UTIs.

Adult

Cystitis:
250 mg PO bid
Pyelonephritis:
500-750 mg PO bid
200-400 mg IV q12h

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce oral absorption; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; quinolones may reduce therapeutic effects of phenytoin; probenecid may increase serum concentrations of quinolones; ciprofloxacin may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Associated with various CNS manifestations, such as hallucinations and seizures; factors that increase risk of adverse effects should be noted when considering use; IV solution of ciprofloxacin should be administered by slow infusion over 60 min to reduce risk of phlebitis


Fosfomycin (Monurol)

Given a "B, I" rating in the 1999 IDSA guidelines for treating UTIs. Phosphonic acid is a bactericidal agent, active against most UTI pathogens, including E coli and Enterobacter, Klebsiella, and Enterococcus species. Little cross-resistance between fosfomycin and other antibacterial agents exists. Primarily excreted unchanged in the urine, and concentrations remain high for 24-48 h after a single dose. It is unique, but quite expensive.

Adult

3 g PO in 4 oz of water as single dose

Pediatric

Not established

Food and antacids decrease absorption

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adverse effects include diarrhea, vaginitis, and nausea


Ofloxacin (Floxin)

Quinolone. Antimicrobial activity based on ability to inhibit bacterial DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Differences in chemical structure between quinolones have resulted in altered levels of activity against different bacteria. Altered chemical structure results in toxicity differences as well. Quinolones have been given an "A, I" or "A, II" rating in the 1999 IDSA guidelines for treating UTIs.

Adult

200-400 mg PO bid
200-400 mg IV q12h

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce oral absorption; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; quinolones may reduce therapeutic effects of phenytoin; probenecid may increase serum concentrations of quinolones; may increase toxicity of caffeine, cyclosporine, and digoxin (monitor levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Quinolones increase risk of pseudomembranous colitis caused by C difficile; may cause severe photosensitivity reactions in patients exposed to sunlight or UV light; have been associated with various CNS manifestations, such as hallucinations and seizures; factors that increase risk of adverse effects should be noted when considering use of any quinolone


Levofloxacin (Levaquin)

Quinolone. Antimicrobial activity based on ability to inhibit bacterial DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Differences in chemical structure between quinolones have resulted in altered levels of activity against different bacteria. Altered chemical structure results in toxicity differences as well. Quinolones have been given an "A, I" or "A, II" rating in the 1999 IDSA guidelines for treating UTIs.

Adult

250-500 mg PO/IV qd

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce oral absorption; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; quinolones may reduce therapeutic effects of phenytoin; probenecid may increase serum concentrations of quinolones; may increase toxicity of caffeine, cyclosporine, and digoxin (monitor levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy


Ertapenem (Invanz)

Bactericidal activity results from inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin binding proteins. Stable against hydrolysis by various beta-lactamases including penicillinases, cephalosporinases, and extended spectrum beta-lactamases. Hydrolyzed by metallo-beta-lactamases.

Adult

1 g IV qd for 14 d if given IV and 7 d if given IM; infuse over 30 min if given IV

Pediatric

Not established

Probenecid may reduce renal clearance of ertapenem and increase half-life but benefit is minimum and does not justify coadministration

Documented hypersensitivity to drug or amide type anesthetics

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Pseudomembranous colitis may occur; seizures and CNS adverse reactions may occur; when using with lidocaine to administer intramuscularly, avoid inadvertent injection into blood vessel

More on Urinary Tract Infection, Females

Overview: Urinary Tract Infection, Females
Differential Diagnoses & Workup: Urinary Tract Infection, Females
Treatment & Medication: Urinary Tract Infection, Females
Follow-up: Urinary Tract Infection, Females
Multimedia: Urinary Tract Infection, Females
References
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Further Reading

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Keywords

urinary tract infection, UTI, urinary infection, cystitis, pyelonephritis, bacteriuria, candiduria, urosepsis, sexually transmitted disease, STD, Escherichia coli, E coli, Pseudomonas aeruginosa, P aeruginosa, Klebsiella pneumoniae, K pneumoniae, candidal species, enterococcal species, enterococci, pelvic inflammatory disease, PID, yeast infection, uropathogens, hematuria, indwelling urethral catheter, indwelling urethral catheterization

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Contributor Information and Disclosures

Author

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey M Tessier, MD, Assistant Professor, Department of Medicine, Uniformed Services University of the Health Sciences
Jeffrey M Tessier, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine
Disclosure: Nothing to disclose.

Mary F Bavaro, MD, Chief, Division of Infectious Disease, Navy Medical Center, San Diego
Mary F Bavaro, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: sepracor Ownership interest None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation
Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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