Urinary Tract Infection Organism-Specific Therapy

Updated: Dec 29, 2022

Author: Daniella Lamour, DO; Chief Editor: Thomas E Herchline, MD

Specific Organisms and Therapeutic Regimens

Organism-specific therapy for urinary tract infection (UTI) should be based on in vitro susceptibility data from a patient-specific isolate, as wide geographic variability exists.[1, 2, 3, 4, 5] The narrowest-spectrum drug that retains appropriate susceptibility is recommended, even if multiple agents including the initial empiric choice are found to have susceptibility.

Fluoroquinolones, such as ciprofloxacin and levofloxacin, while highly effective for uncomplicated infection, have added risks, including central nervous system effects (ie, neuropathy, dizziness), gastrointestinal effects (ie, vomiting, diarrhea), and the propensity to select for subsequent infection with more resistant organisms, and thus should be reserved for other uses.[6, 7]

Uncomplicated urinary tract infections

Escherichia coli[8, 9, 10, 11, 12]

Trimethoprim/sulfamethoxazole 160 mg/800 mg (1 DS tablet) PO BID for 3-5 days or
Nitrofurantoin macrocrystals 50-100 mg PO QID for 5 days or
Nitrofurantoin sustained-release 100 mg PO BID for 5 days or
Fosfomycin 3g PO once
Pivmecillinam 400mg BID or TID for 3-5 days
Ciprofloxacin 250-500 mg PO BID or extended-release 1000 mg PO daily for 3-5 days or
Levofloxacin 250 mg PO daily for 3-5 days

Staphylococcus saprophyticus [13]

Nitrofurantoin 100 mg PO BID for 5 days or
Trimethoprim-sulfamethoxazole 160 mg/800 mg PO BID for 3 days or
Cephalexin 500 mg PO QID for 5 days or
Amoxicillin/clavulanate 875/125 mg PO BID for 5 days or
Ciprofloxacin 250 mg PO BID or extended-release 500 mg PO daily for 3 days or
Levofloxacin 250 mg PO daily for 3 days

Klebsiella species[14]

Trimethoprim/sulfamethoxazole 160 mg/800 mg (1 DS tablet) PO BID for 3 days or
Ciprofloxacin 250 mg PO BID or extended-release 500 mg PO daily for 3 days or
Levofloxacin 250 mg PO daily for 3 days or
Nitrofurantoin macrocrystals 50-100 mg PO QID for 5 days or
Nitrofurantoin sustained-release 100 mg PO BID for 5 days

Proteus species

Trimethoprim/sulfamethoxazole 160 mg/800 mg (1 DS tablet) PO BID for 3 days or
Ciprofloxacin 250 mg PO BID or extended-release 500 mg PO daily for 3 days

Enterobacteriaceae species[15]

Fosfomycin 3g PO once or
Pivmecillinam 400mg BID or TID for 3-5 days days or
Nitrofurantoin macrocrystals 50-100 mg PO QID for 5 days or
Nitrofurantoin sustained-release 100 mg PO BID for 5 days or
Trimethoprim/sulfamethoxazole 160 mg/800 mg (1 DS tablet) PO BID for 3 days or
Ciprofloxacin 250 mg PO BID or extended-release 500 mg PO daily for 3 days or
Levofloxacin 250 mg PO daily for 3 days

Pseudomonas aeruginosa

Ciprofloxacin 500-750 mg PO BID for 3 days
Discuss alternatives with an infectious disease specialist

Candida species

Fluconazole 200-mg loading dose followed by 100 mg PO daily for at least 4 days
Discuss alternatives with an infectious disease specialist

Complicated urinary tract infections

In vitro susceptibility is essential to guide therapy, as high-level drug resistance is more frequently encountered in the patient with complicated UTI (cUTI).[16] Early consideration of consultation with an infectious diseases specialist is prudent to ensure optimal therapy.

The duration of therapy can be reduced in patients who have prompt resolution of symptoms and who are not severely ill; 7 days of therapy could be considered in patients who respond rapidly, whereas a longer duration (10-14 days) may be considered in patients who have a delayed response.[16]

The narrowest-spectrum drug that retains appropriate susceptibility is recommended, even if multiple agents, including the initial empiric choice, are found to have susceptibility. In addition, fluoroquinolones, such as ciprofloxacin and levofloxacin, have added risks, including the propensity to select for subsequent infection with more resistant organisms, and thus should be reserved for other uses.[6]

Escherichia coli[6, 17, 18, 19, 20]

Trimethoprim/sulfamethoxazole 160 mg/800 mg (1 DS tablet) PO BID for 7-14 days or
Cefdinir 300 mg PO BID for 7-14 days or
Cefadroxil 1 g PO BID for 7-14 days or
Cefpodoxime 200 mg PO BID for 7-14 days or
Piperacillin-tazobactam 3.375 g IV q6h for 7-14 days or
Cefazolin 1-2 g IV q8h for 7-14 days or
Ceftriaxone 2 g IV q24h for 7-14 days or
Ertapenem 1 g IV q24h for 7-14 days or
Imipenem-cilastatin 500 mg IV q6h for 7-14 days or
Meropenem 1-2 g IV q8h for 7-14 days or
Ciprofloxacin 500 mg PO BID or 400 mg IV q12h or extended-release 1 g PO daily for 7-14 days or
Levofloxacin 750 mg PO or IV daily for 5-14 days
Plazomicin 15 mg/kg IV q24hr for up to 7 days (reserve for patients with cUTI who have limited or no alternative treatment options)

Staphylococcus saprophyticus[13]

Amoxicillin-clavulanate 875-125 mg PO BID for 7-14 days or
Ampicillin-sulbactam 3 g IV q6h for 7-14 days or
Cephalexin 500 mg PO QID for 7-14 days or
Cefadroxil 1 g PO BID for 7-14 days or
Trimethoprim/sulfamethoxazole 160 mg/800 mg (1 DS tablet) PO BID for 7-14 days or
Cefazolin 1-2 g IV q8h for 7-14 days or
Ceftriaxone 2 g IV q24h for 7-14 days or
Ciprofloxacin 500 mg PO BID or 400 mg IV q12h or extended-release 1 g PO daily for 7-14 days or
Levofloxacin 750 mg PO or IV daily for 7-14 days

Klebsiella species

Trimethoprim/sulfamethoxazole 160 mg/800 mg (1 DS tablet) PO BID for 7-14 days or
Piperacillin-tazobactam 3.375 g IV q6h for 7-14 days or
Cefazolin 1-2 g IV q8h for 7-14 days or
Ceftriaxone 2 g IV q24h for 7-14 days or
Ertapenem 1 g IV q24h for 7-14 days or
Imipenem-cilastatin 500 mg IV q6h for 7-14 days or
Meropenem 1-2 g IV q8h for 7-14 days or
Ciprofloxacin 500 mg PO BID or 400 mg IV q12h or extended-release 1 g PO daily for 7-14 days or
Levofloxacin 750 mg PO or IV daily for 7-14 days or
Plazomicin 15 mg/kg IV q24hr for up to 7 days (reserve for patients with cUTI who have limited or no alternative treatment options)[20]

Proteus species

Trimethoprim/sulfamethoxazole 160 mg/800 mg (1 DS tablet) PO BID for 7-14 days or
Cefazolin 2 g IV q8h for 7-14 days or
Ceftriaxone 2 g IV q24h for 7-14 days or
Ertapenem 1 g IV q24h for 7-14 days or
Imipenem-cilastatin 500 mg IV q6h for 7-14 days or
Meropenem 1-2 g IV q8h for 7-14 days or
Ciprofloxacin 500 mg PO BID or 400 mg IV q12h or extended-release 1 g PO daily for 7-14 days or
Levofloxacin 750 mg PO or IV daily for 7-14 days or
Plazomicin 15 mg/kg IV q24hr for up to 7 days (reserve for patients with cUTI who have limited or no alternative treatment options)[20]

Enterobacteriaceae species [15]

Trimethoprim/sulfamethoxazole 160 mg/800 mg (1 DS tablet) PO BID for 7-14 days or
Piperacillin-tazobactam 3.375 g IV q6h for 7-14 days or
Cefazolin 1- 2 g IV q8h for 7-14 days or
Ceftriaxone 2 g IV q24h for 7-14 days or
Ertapenem 1 g IV q24h for 7-14 days or
Imipenem-cilastatin 500 mg IV q6h for 7-14 days or
Meropenem 1-2 g IV q8h for 7-14 days or
Ciprofloxacin 500 mg PO BID or 400 mg IV q12h or extended-release 1 g PO daily for 7-14 days or
Levofloxacin 750 mg PO or IV daily for 7-14 days or
Plazomicin 15 mg/kg IV q24hr for up to 7 days (reserve for patients with cUTI who have limited or no alternative treatment options)[20]

Pseudomonas aeruginosa

Piperacillin-tazobactam 4.5 g IV q6h for 7-14 days or
Ceftazidime 2 g IV q6-8h for 7-14 days or
Cefepime 2 g IV q8h for 7-14 days or
Imipenem-cilastatin 500 mg IV q6h for 7-14 days or
Meropenem 1-2 g IV q8h for 7-14 days or
Ciprofloxacin 500-750 mg PO BID or 400 mg IV q12h or extended-release 1 g PO daily for 7-14 days or
Levofloxacin 750 mg PO or IV daily for 7-14 days

Enterococcus faecalis

Amoxicillin 500 mg PO TID for 7-14 days
Discuss alternatives with an infectious disease specialist

Author

Daniella Lamour, DO Resident Physician, Department of Emergency Medicine, Florida Atlantic University Charles E Schmidt College of Medicine

Daniella Lamour, DO is a member of the following medical societies: American Academy of Emergency Medicine, American College of Osteopathic Emergency Physicians, Emergency Medicine Residents' Association, Florida College of Emergency Physicians, National Medical Association, Palm Beach County Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Joshua J Solano, MD, FAAEM, FACEP Associate Professor of Emergency Medicine, Emergency Medicine Medical Student Clerkship Director, Florida Atlantic University

Joshua J Solano, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Florida Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio

Disclosure: Received research grant from: Regeneron.

Additional Contributors

Nirav Patel, MD † Assistant Professor of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, and Division of Pulmonary, Critical Care, and Sleep Medicine, St Louis University School of Medicine; Chief Medical Officer, Director of Antibiotic Stewardship, Infection Control Officer, St Louis University Hospital

Nirav Patel, MD is a member of the following medical societies: American Medical Association, Infectious Diseases Society of America, Infectious Diseases Society of St Louis, Missouri State Medical Association, Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Acknowledgements

Stephen L Thornton, MD Assistant Professor of Emergency Medicine, University of Kansas Hospital

Stephen L Thornton, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Urinary Tract Infection Organism-Specific Therapy

Specific Organisms and Therapeutic Regimens

Uncomplicated urinary tract infections

Complicated urinary tract infections

Contributor Information and Disclosures

References