eMedicine Specialties > Emergency Medicine > Genitourinary
Urinary Tract Infection, Female: Treatment & Medication
Updated: Nov 20, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- With few exceptions, the vast majority of adult patients with UTI present to the ED on an ambulatory basis.
- Exceptions include the immunocompromised or elderly patient who has UTI manifesting as a sepsis syndrome with circulatory insufficiency. In this situation, mental status changes (eg, confusion) or profound weakness may prompt paramedical transport to the hospital.
- Findings of hypotension, tachycardia, and delayed capillary refill require intravenous (IV) fluid resuscitation in the field.
Emergency Department Care
- Ambulatory patients who have symptoms and findings consistent with UTI, who have stable vital signs, and who otherwise appear well may be treated on an outpatient basis.
- Oral therapy with an antibiotic effective against gram-negative aerobic coliform bacteria, such as E coli, is the principal treatment intervention in patients with UTI. The patient with an uncomplicated presumed lower UTI or simple cystitis who has symptoms of less than 48 hours' duration may be treated with one of the following agents for a total of 3 days:2
- Co-trimoxazole DS (double strength) (eg, Bactrim, Septra): The Infectious Disease Society of America recommends the use of Bactrim as first-line therapy in patients without an allergy and in areas where resistance if not high (>15%).
- Ciprofloxacin or similar fluoroquinolone: Reserving the use of fluoroquinolones for complicated infections or cases with documented drug resistance may help decrease the incidence of bacterial resistance to drugs in the fluoroquinolone class. These drugs must be avoided in pregnancy.
- Nitrofurantoin macrocrystals (eg, Macrodantin)
- Amoxicillin/clavulanate (eg, Augmentin)
- Practice guidelines on treatment of UTI in nonpregnant women are available from the American College of Obstetricians and Gynecologists.3
- If the patient has intense dysuria, offering a bladder analgesic, such as phenazopyridine (Pyridium), for 1-2 days is a considerate gesture on the part of the treating physician. Avoid use if the patient has a sulfa allergy. Many authors advise stressing the intake of plenty of fluids to promote a dilute urine flow.
- Pregnant, otherwise healthy women with no evidence of an upper UTI should be treated with a 14-day course of a cephalosporin, as most obstetrics authorities prefer prolonged treatment even in the absence of signs of upper tract disease. More recently, many authors have recommended a 10- to 14-day course of nitrofurantoin macrocrystals (eg, Macrodantin) as a preferred first-line agent due to increased resistance to cephalosporins. Pregnant patients should be treated for all episodes of pyuria or bacteriuria, regardless of whether they have symptoms. Successful outpatient treatment of a subset of pregnant patients with clinically evident pyelonephritis has been reported. They must be less than 24 weeks' pregnant, hemodynamically stable, and able to tolerate oral fluids and medications. A urine culture should be performed in all pregnant patients.
- Ambulatory younger women who present with signs and symptoms of pyelonephritis may be candidates for outpatient therapy. They must be otherwise healthy and must not be pregnant. They must be treated initially in the ED with vigorous oral or IV fluids, antipyretic pain medication, and a dose of parenteral antibiotics. Studies have shown that outpatient therapy for selected patients was as safe as, and much less expensive than, inpatient therapy for a comparable group of patients.
- A popular regimen for the outpatient treatment of young, otherwise healthy nonpregnant women at the authors' institution is referred to as "treatment by (the rule of) twos."
- In the ED, patients receive 2 liters of fluid (IV or orally), 2 Tylenol #3, and 2 g of ceftriaxone IV.
- The patient can go home if her temperature drops by 2°F and she is able to tolerate 2 glasses of water.
- On discharge, the patient must take 2 co-trimoxazole DS 2 times per day for 2 weeks (or ciprofloxacin, 500 mg, 2 times per day for 1-2 wk). Establish follow-up in 2 days.
- The decision regarding admission of a patient with acute pyelonephritis is dependent on age; host factors, such as immunocompromising chemotherapy or chronic diseases, known urinary tract structural abnormalities, renal calculi, recent hospitalization, or urinary tract instrumentation; and the patient's response to ED therapy. Initial treatment should include the following:
- IV antibiotic therapy using co-trimoxazole (eg, Bactrim, Septra), which is directed at coliform gram-negative bacteria, such as E coli; a third-generation cephalosporin, such as ceftriaxone (eg, Rocephin); a carbapenem beta-lactam, such as ertapenem (eg, Invanz); or an aminoglycoside, such as tobramycin. Most authors recommend monotherapy unless the urine Gram stain reveals gram-positive cocci; in this case, add ampicillin to the antibiotic regimen to cover enterococci (eg, Streptococcus faecalis).
- Adequate fluid resuscitation restores effective circulating volume and generous urinary volumes.
- Antipyretic pain medications may be administered, as appropriate.
- Imaging studies are often helpful; consider while the patient is still in the ED.
- Recognition of obstruction with hydronephrosis may require acute intervention by a consultant urologist to effect a bacteriologic cure.
Consultations
- Evidence of obstruction, hydronephrosis, perinephric abscess, or other structural abnormality requires urologic consultation.
- In the patient with a complicated UTI, coverage for unusual or multiple antibiotic resistant organisms (eg, Pseudomonas aeruginosa) must be considered. An infectious disease consultation may be helpful in selecting the appropriate antimicrobial agent.
Medication
Antibiotics are the principal medications needed in treatment of UTI. Adjunctive measures include bladder anesthetics, antipyretics, interventions for the control of pain or nausea, and correction of dehydration.
Antibiotics
Empiric antimicrobial therapy should cover all likely pathogens in the context of this clinical setting.
Sulfamethoxazole and trimethoprim (Bactrim, Septra, Cotrim)
Inhibits bacterial synthesis of dihydrofolic acid by competing with paraaminobenzoic acid. This results in inhibition of bacterial growth. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.
Adult
160 mg TMP/800 mg SMZ PO q12h; for simple cystitis, administer 3 d; for complicated UTI/pyelonephritis, administer 10-14 d
Pediatric
<2 months: Do not administer
>2 months: 2 mg/kg/dose (based on TMP) PO qd
Warfarin may increase PT (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; diuretics increase incidence of thrombocytopenia purpura in elderly; may increase phenytoin levels; may potentiate effects of methotrexate in bone marrow depression; may increase hypoglycemic response to sulfonylureas; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
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 rash or sign of adverse reaction; obtain CBCs frequently—discontinue therapy if significant hematologic changes occur; sulfonamides may cause goiter production, diuresis, and hypoglycemia; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation; hemolysis may occur in individuals with glucose-6-phosphate dehydrogenase deficiency (usually dose dependent)
Ciprofloxacin (Cipro)
Indicated for pseudomonal infections and infections due to multidrug-resistant gram-negative organisms.
Adult
250-500 mg PO bid; for simple cystitis, administer 3 d; for complicated UTI/pyelonephritis, administer 10-14 d
Pediatric
<18 years: Use with caution; approved for use in complicated pediatric UTI
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may interfere with GI absorption, resulting in decreased serum levels (administer antacids 2-4 h before or after fluoroquinolone); cimetidine may interfere with metabolism; may reduce therapeutic effects of phenytoin; probenecid may significantly increase serum concentrations; may increase theophylline and caffeine concentrations and prolong their duration of action; may increase nephrotoxic effect of cyclosporine; may increase digoxin serum levels (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity to quinolones
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 including renal, hepatic, and hematopoietic; patients with renal function impairment may require dose adjustment; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms, resulting in secondary infections; take appropriate measures to prevent further complications
Ceftriaxone (Rocephin)
Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to one or more of penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth. Useful as outpatient IV treatment for pyelonephritis and for complicated or upper UTI. Comparable third-generation cephalosporins with broad gram-negative antibacterial activity are also acceptable. When pseudomonal coverage is an issue, consider using ceftazidime.
Adult
Depending on type and severity of infection, administer 1-2 g IV qd or divided bid; not to exceed 4 g/d
Pediatric
<7 days: Not established
>7 days: 25-50 mg/kg IV as single dose; not to exceed 125 mg/dose
Infants and children: 125 mg IV as single dose plus doxycycline
Serious infection: 50-75 mg/kg/d IV divided q12h; not to exceed 2 g/d
Probenecid may increase levels; ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
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; caution in breastfeeding women and allergy to penicillin
Tobramycin (Nebcin)
Used in skin, bone and skin-structure infections caused by Staphylococcus aureus, P aeruginosa, E coli, and Klebsiella, Proteus, and Enterobacter species. Indicated in treatment of staphylococcal infections when penicillin or potentially less-toxic drugs are contraindicated and when bacterial susceptibility and clinical judgment justify its use. Dosing regimens are numerous and are adjusted on basis of CrCl and changes in volume of distribution.
Adult
Serious infections and normal renal function: 3 mg/kg IV/IM q8h
Extended dosing regimen for life-threatening infections: 5 mg/kg IV/IM q6-8h
Usual loading dose: 1-2.5 mg/kg IV; maintenance dose, 1-1.5 mg/kg IV q8h
Each regimen must be followed by at least trough level drawn on third or fourth dose 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion
Pediatric
<5 years with normal renal function: 2.5 mg/kg IV/IM q8h
>5 years: 1.5-2.5 mg/kg IV/IM q8h or 6-7.5 mg/kg/d IV/IM divided q8h; not to exceed 300 mg/d; adjustments for renal function as needed; monitor levels as in adults
Increases effects of neuromuscular blockers; potentiates effect of extended spectrum penicillins; amphotericin B, cephalosporins, and loop diuretics increase risk of nephrotoxicity
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid use in renal impairment, preexisting auditory or vestibular impairment, and neuromuscular disorders; associated with nephrotoxicity and ototoxicity
Cephalexin (Keflex)
First-generation cephalosporin that inhibits bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls.
Adult
250-1000 mg PO q6h for 10-14 d; not to exceed 4 g/d
Pediatric
25-50 mg/kg PO divided q6h; not to exceed 3 g/d
Aminoglycosides increase nephrotoxic potential
Documented hypersensitivity
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
Amoxicillin and clavulanate (Augmentin)
Drug combination that treats bacteria normally resistant to beta-lactam antibiotics.
Adult
500 mg PO q12h or 250 mg PO q8h
Pediatric
<3 months: 125 mg/5 mL PO susp, based on amoxicillin
<40 kg body weight: 20-40 mg/kg/d PO divided bid
>40 kg body weight: Administer as in adults
Warfarin and heparin increase risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Give for minimum of 10 d to eliminate organism and prevent sequelae (endocarditis, rheumatic fever); following treatment, perform cultures to confirm eradication of pathogen
Nitrofurantoin (Macrodantin, Furadantin, Macrobid)
Synthetic nitrofuran that interferes with bacterial carbohydrate metabolism by inhibiting acetylcoenzyme A. At low concentrations (5-10 mcg/mL), bacteriostatic. At higher concentrations, bactericidal.
Adult
50-100 mg/dose PO q6h
Sustained release: 100 mg PO bid
Pediatric
<1 month: Not established
>1 month: 5-7 mg/kg/d PO divided q6h; not to exceed 400 mg/d
Anticholinergics may delay gastric emptying and may increase absorption and bioavailability; antacids made of magnesium salts may decrease effects by decreasing absorption; high doses of probenecid decrease renal clearance and increase toxicity
Documented hypersensitivity; renal insufficiency (CrCl <60 mL/min), anuria, or oliguria (increased risk of toxicity); pregnant patients at term (38-42 weeks) or during labor and delivery; neonates <1 month old
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause severe and irreversible peripheral neuropathy that can be fatal; renal impairment, diabetes, electrolyte imbalance, anemia, and vitamin B deficiency increase risk of this adverse effect; prolonged use may result in fungal or bacterial overgrowth of resistant or nonsusceptible organisms; interstitial pneumonitis or pulmonary fibrosis can develop insidiously; hepatitis, cholestatic jaundice, and hepatic necrosis occur rarely
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 a variety of beta-lactamases including penicillinases, cephalosporinases, and extended spectrum beta-lactamases. Hydrolyzed by metallo-beta-lactamases.
Adult
1 g 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
Analgesics, urinary
These agents relieve pain, discomfort, and spasms of the bladder.
Phenazopyridine (Pyridium)
Azo dye excreted in urine, where it exerts topical analgesic effect on urinary tract mucosa. Compatible with antibacterial therapy and can help relieve pain and discomfort before antibacterial therapy controls infection. Used for symptomatic relief of pain, burning, urgency, frequency, and other discomforts arising from irritation of lower urinary tract mucosa caused by infection, trauma, surgery, endoscopic procedures, or passage of sounds or catheters. Analgesic action may reduce or eliminate need for systemic analgesics or narcotics.
Adult
200 mg PO tid for 2 d or prn for relief of symptoms
Pediatric
<6 years: Not established
6-12 years: 12 mg/kg/d divided tid PO for 2 d
>12 years: Administer as in adults
None reported
Documented hypersensitivity; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dosage in patients diagnosed with renal insufficiency; yellowish tinge of skin or sclerae may indicate accumulation because of impaired renal excretion (discontinue therapy if this occurs); treatment should not exceed 2 d because no evidence suggests that is more beneficial than antibiotic alone following 2 d of therapy
More on Urinary Tract Infection, Female |
| Overview: Urinary Tract Infection, Female |
| Differential Diagnoses & Workup: Urinary Tract Infection, Female |
 Treatment & Medication: Urinary Tract Infection, Female |
| Follow-up: Urinary Tract Infection, Female |
| References |
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References
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Further Reading
Keywords
urinary tract infection women, UTI women, UTI treatment, UTI diagnosis, UTI symptoms, hemorrhagic cystitis, urinary urgency, cystitis, pyelonephritis, bacteriuria, enteric coliform bacteria, Escherichia coli
