Empiric treatment regimens for urinary tract infections, (when culture results are awaited)

Urinary syndrome

Drug of choice

Alternative choice

Comments
Acute cystitis
  • Nitrofurantoin
  • Fosfomycin
  • Co-trimoxazole
  • Ertapenem
  • Amikacin (can be used in children as well)
  • Dosage adjustment as per eGFR.
  • Fosfomycin and nitrofurantoin should be avoided when there is suspicion of pyelonephritis or prostatitis / presence of systemic features of infection.
  • Fosfomycin susceptibility to being requested for, and used only for Gram-negative MDR organisms.
Acute Pyelo-nephritis
  • Piperacillin –tazobactam
  • Ertapenem
  • Imipenem
  • Meropenem
  • Amikacin (recommended for children as well)
  • Dosage adjustment as per eGFR.
  • Treatment is for a minimum of 7 days.
  • The total duration of treatment is 14 days in children.
  • Same treatment regimen to be used for complicated UTI except the duration is extended (7-14 days).
Acute Prostatitis
  • Ertapenem 1 g IV once daily
  • Piperacillin-tazobactam
  • Imipenem
  • Meropenem
  • Trimethoprim-Sulfamethoxazole
 Urine and prostatic massage specimen for cultures to be collected before antibiotics.
Prostatitis requires a minimum of 21 days antibiotics.
Epididymo-orchitis (High risk of sexually transmitted) Ceftriaxone +
Doxycycline
  • Ofloxacin
  • Levofloxacin
Total duration of treatment is 14 days (except for Levofloxacin where it is 10 days)
Epididymo-orchitis (Low risk of sexually transmitted; likely due to enteric or urinary organisms)
  • Ofloxacin
  • Levofloxacin

    • *ICMR, AMRSN data 2017

    Note: -

    1. Local antimicrobial resistance patterns should be the basis for empiric treatment.
    2. For acute pyelonephritis, three strategies may be employed: hospital admission, completely outpatient parenteral antibiotic therapy (OPAT) or single dose of parenteral antibiotic and supportive care in emergency room before home discharge with subsequent OPAT.
    3. Antibiotics should be changed based on susceptibility results as soon as they are available.
    4. Intravenous antibiotics must be reviewed at 48 hours, and stepping down to oral antibiotics should be considered.
    5. Post-treatment urine cultures in asymptomatic patients are not indicated routinely.
    6. UTIs in males are usually complicated and uncommon in the absence of obstructive pathology.
    7. No antibiotic treatment is required when there is the presence of pus cells in urine, along with negative culture results or in those with asymptomatic bacteriuria. If the pyuria persists, causes for sterile pyuria should be investigated.