VIHA ALGORITHM for URINARY TRACT INFECTION

In ADULT PATIENTS (Rev. March 2011)

Complicating Factors for UTI &
Pyelonephritis Treatment Signs and Symptoms of Suspected UTI
ƒ Women > 55 yrs • Dysuria in combination with frequency, urgency,
ƒ Men suprapubic pain, and/or hematuria IV to PO step-down criteria (all
ƒ Symptoms lasting > 7 days • Usually in the absence of vaginal symptoms of the following must be met)
ƒ Diabetes Mellitus • Pyuria on routine urinalysis ƒ Temp< 38 ºC X 24 hours
ƒ Structural abnormality of urinary • Nitrite positive (for gram negatives)
tract (e.g. urethral stricture, renal
ƒ WBC < 11 or decreasing trend
calculi, tumor, abscess)
ƒ Clinical improvement while on
Ensure urine has been collected for C & S. IV treatment
ƒ Spinal cord injury *Catheterized patients – replace catheter and
ƒ Multiple sclerosis
ƒ Absence of GI abnormalities
collect specimen through a clean catheter. that may reduce absorption
ƒ Pregnancy
ƒ Chronic catheterization
ƒ Recurrent UTI Presence of Additional Signs & Symptoms?
• Fever (Temperature ≥ 38.5 ºC)
• Flank pain
• Abdominal or pelvic pain Pyelonephritis
• Nausea/vomiting
Cystitis NO YES
• Costovertebral tenderness
• Presence of white cell casts on urinalysis

Collect blood cultures X 2 (in addition to urine C & S)

Uncomplicated Complicated
(see box top left for criteria)
Complicated
Uncomplicated (see box top left for criteria)

Oral Options Oral Options

- nitrofurantoin* 100 mg BID X 5 days - amoxicillin-clavulanate 500/125 mg TID
(Pregnancy: avoid near term, greater - TMP/SMX§ 1 DS tab BID IV Options
than 35 weeks) (Pregnancy: avoid in1st trimester and last IV Options GFR ≥ 60 ml/min
- TMP/SMX 1 DS tab BID X 3 days 6 weeks) GFR ≥ 60 ml/min - gentamicin† 5-7 mg/kg q 24h
(Pregnancy: avoid in1st trimester and - gentamicin† 5- 7 mg/kg q 24h + ampicillin 1 g q 6h
last 6 weeks) GFR < 60ml/min GFR < 60ml/min
- cefixime 400 mg daily X 3 days - ceftriaxone 1 g q 24 h - ceftriaxone 1 g q 24h
+ ampicillin 1 g q 6-12h
Oral Options
Tailor therapy once C & S results obtained and - TMP/SMX 1 DS tab BID Oral Options
treat for a total of 7 days (Pregnancy: avoid in1st trimester and - amoxicillin-clavulanate 500/125 mg TID
last 6 weeks) - TMP/SMX§ 1 DS tab BID
For structural abnormality of urinary tract or for (Pregnancy: avoid in1st trimester and last
catheterized patients, treat for 10-14 days 6 weeks)

Tailor therapy once

C & S results obtained and step
Notes Tailor therapy once
* down to PO treatment when
MACROBID formulation
§ appropriate (see box top right for C & S results obtained and step down to
These agents do not provide Enterococcal coverage
† criteria) PO treatment when appropriate (see box
Gentamicin should be stepped down to an alternative oral agent as soon as possible due to the risk of
top right for criteria)
vestibular, oto, & nephro toxicity associated with prolonged treatment
Treat for total 10-14 days (or 7
days if fluoroquinolone used for Treat for a total of 14 days and conduct
Antimicrobial use within last 90 days should be considered when selecting antimicrobial
definitive treatment) follow-up urine C&S.
regimen for all patients.