In this episode, I’ll discuss recent guidelines about complicated UTI treatment.
For the first time ever, the IDSA has published a set of guidelines specific to the treatment of complicated UTIs. A complicated UTI is now defined as any UTI that is not confined to the bladder. This could be pyelonephritis, febrile or bacteremic UTI, catheter-associated UTI, or even prostatitis.
The IDSA suggests the following 4-step approach to empiric antibiotic selection:
Step 1: Assess the severity of illness
Step 2: Evaluate risk factors for resistant organisms
Step 3: Assess patient-specific factors
Step 4: If the patient has sepsis, consult your local antibiogram
The severity of illness could range from sepsis with or without shock, to no sepsis. A SOFA score of 2 or higher can be used to identify sepsis, although the qSOFA or SIRS criteria may be used instead.
Risk factors for resistant organisms and patient-specific factors could range from prior antibiotic exposure to prior urine cultures to allergies.
For patients with sepsis and complicated UTI, the IDSA guideline authors suggest initially selecting among third- or fourth-generation cephalosporins, carbapenems, piperacillin-tazobactam, or fluoroquinolones rather than newer agents or aminoglycosides.
For patients without sepsis and complicated UTI, the IDSA guideline authors suggest initially selecting among third- or fourth-generation cephalosporins, piperacillin-tazobactam, or fluoroquinolones rather than carbapenems, newer agents or aminoglycosides.
The third and fourth generation IV cephalosporins recommended by the guideline authors include: ceftriaxone, ceftazidime, cefotaxime, and cefepime.
You might wonder when it comes time to select empiric therapy for patients with sepsis from a complicated UTI, why do the guideline authors want you to consult an antibiogram? Empiric therapy gets selected before culture and sensitivity data are back, so on the surface, this is a puzzling recommendation.
The guideline authors suggest that you first look for previous urine cultures the patient has had and choose an antibiotic that has adequate coverage against the identified bug, according to the previous culture and your antibiogram. However, if you don’t have a previous urine culture to guide you, you assume the pathogen is E. coli and choose an antibiotic that has adequate coverage against E. coli according to your antibiogram.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Leave a Reply