Urinary Tract

Infections in Adults
Translated from the original French version published October 2009
This clinical guide is provided for information purposes and is not a substitute for the practitioners judgment.

GENERAL
90% of urinary tract infections (UTIs) are caused by enterobacteria.
Most common pathogens: Escherichia coli, Staphylococcus saprophyticus, enterococci
Uncomplicated UTIs occur:
Usually in women of childbearing age
In lower urinary tract, without anatomic abnormality
Complicated UTIs occur in:
Men and children
Pregnant women
Patients with urinary catheters or those waiting for urinary catheterization
Upper urinary tract
In case of:
- Anatomic abnormality of the urinary tract
- Diabetes mellitus
- Immunosuppression
- Symptoms developing for over 7 days

DIAGNOSIS
Urine analysis test (microscopic or stick): simple, low cost and reliable
Presence of nitrites, leukocytes and de novo urinary tract symptoms: good predictive value of UTI
Absence of nitrites or leukocytes: good negative predictive value
Urine culture
Not very useful in uncomplicated UTIs (except if reccurence < 1 month)
Recommended in complicated UTIs or if persistent symptoms

TREATMENT GUIDELINES
Asymptomatic bacteriuria:
Treat only pregnant women and patients undergoing genito-urinary surgery.
Antimicrobial therapy in pregnant women must be adapted to their condition.

Uncomplicated UTIs
3-day therapy:
The standard for treating uncomplicated cystitis in women. May also be used in women over 65
without anatomic abnormality of the urinary tract.
Only TMP-SMX and fluoroquinolones may be prescribed for 3 days.
Trimethoprim-sulfamethoxazole (TMP-SMX):
In Qubec, approximately 15% of enterobacteria are resistant to TMP-SMX.
TMP-SMX is first-line treatment EXCEPT when local resistance exceeds 20%,
when there has been recent antimicrobial treatment with TMP-SMX or recent hospitalization.
It is preferable to know the prevalence of local resistance before prescribing.
In case of sulfonamide allergy, trimethoprim alone is an alternative.
-lactams and nitrofurantoin:
Efficacy proven in 7-day courses.

www.cdm.gouv.qc.ca

Acute pyelonephritis (APN)

In patients capable of taking oral therapy:
- Fluoroquinolones constitute first-line empirical therapy.
- Pregnancy must be excluded in women of childbearing age.
In severe APN cases requiring hospitalization:
- Oral or parenteral fluoroquinolone OR
- Combination of aminoglycoside OR extended-spectrum cephalosporin WITH ampicillin if enterococcus is suspected.
Duration of therapy for APN is 14 days; initiate oral therapy as soon as possible.
The presence or possibility of urinary tract obstruction is considered an emergency.

Treatment of uncomplicated urinary tract infections*

Antibiotic

Oral dosage

Duration

Fluoroquinolone
Ciprofloxacin (Cipro)

250 mg every 12 hours

Ciprofloxacin XL (Cipro XL)

500 mg every 24 hours

Levofloxacin (Levaquin)

250 mg every 24 hours

Norfloxacin (Norflox generic)

400 mg every 12 hours

Ofloxacin (Oflox generic)

200 mg every 12 hours

3 days

Sulfonamide
TMP-SMX (Septra DS generic)

1 tab. every 12 hours

TMP (Apo-Trimethoprim)

100 mg every 12 hours

Other
Nitrofurantoin (Macrobid)

100 mg every 12 hours

Nitrofurantoin (Novo-Furantoin)

50-100 mg every 6 hours

-lactams
Amoxicillin-clavulanate potassium (Clavulin)

250 mg every 8 hours or

500 mg every 12 hours

Narrow spectrum cephalosporins

ex.: Cefadroxil (Duricef)

500 mg every 12 hours

7 days

Treatment of acute pyelonephritis and complicated urinary tract infections*

Antibiotic

Dosage

Oral therapy
Ciprofloxacin (Cipro)

500 mg PO every 12 hours

Ciprofloxacin XL (Cipro XL)

1 000 mg PO every 24 hours

Levofloxacin (Levaquin)

500 mg PO every 24 hours

Duration

14 DAYS EXCEPT: Young women without

anatomical abnormality of the urinary
tract treated with fluoroquinolones, in
which case: 7 days

Parenteral therapy (severe cases)

Ciprofloxacin (Cipro)

400 mg IV BID

Levofloxacin (Levaquin)

500 mg IV DIE

Initiate oral therapy as soon as possible

Aminoglycoside + ampicillin
OR
Extended-spectrum cephalosporin + ampicillin
* Adjust dosage according to renal function.
The antibiotics are listed in alphabetical order of their generic name within their group. Only one brand name product is listed although several manufacturers
may market other brand names.
Cefadroxil (Duricef), Cefprozil (Cefzil), Cephalexin.

REFERENCES

Lutters M, Vogt-Ferrier NB. Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD001535.
Warren JW, Abrutyn E, Hebel JR, et al. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis. 1999;29:745-58.
Please note that other references have been consulted.

Urinary Tract Infections in Adults

This guide was developed with the collaboration of the professional corporations (CMQ, OPQ), the federations (FMOQ, FMSQ) and Qubec associations of pharmacists and physicians.