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460 Cystitis and Pyelonephritisspecific therapy
■Simple cystitis in woman can be treated with a 3-day oral course of
an appropriate antibiotic.
■Generally, do not treat asymptomatic bacteriuria (pregnancy, kidney
transplant, immunocompromise, anatomic abnormalities, impend-
ing surgery are exceptions to this rule; bladder catheter is not an
exception).
■Complicated urinary tract infections (anatomic abnormality,
obstruction, hospital-acquired organism, indwelling bladder
catheter) require at least 10 days of therapy.
■Urinary tract infections in men are always considered complicated
(and require evaluation of genitourinary anatomy; stongly consider
Urology consultation).
■Pyelonephritis requires 14 days of IV or IV equivalent (oral quin-
olone) therapy.
■Whenever possible, Gram stain should be used to guide empiric
choice of antibiotics.
■Community acquired Gram-negative infections generally respond
to third-generation cephalosporins, quinolones, and trimethoprim-
sulfamethoxazole.
■Ampicillin (or vancomycin for hospital-acquired organisms) is
the agent of choice for Enterococccus sp., though simple cysti-
tis may respond to trimethoprim-sulfamethoxazole, quinolones,
Macrodantin, or doxycycline. Linezolid is effective for Vancomycin-
resistant enterococci but should be reserved for severe or life-
threatening infections.
■Hospital-acquired urinary tract infections may require antipseu-
domonal penicillin with or without a beta-lactamase inhibitor, cef-
tazidime, imipenem, aztreonam, or quinolone therapy.
■Candidal urinary tract infections can be treated with fluconazole. For
resistant Candida sp, a single dose of amphotericin B has been found
effective in some patients. Liposomal formulations of amphotericin
do not penetrate the renal parenchyma or bladder and should not
be used. Newer azoles and echinocandins may play a role in highly
resistant infections. Consider ID consultation.follow-up
■Expect rapid (within 24 h) improvement for treatment of acute uri-
nary tract infections.
■If improvement not rapid, consider complications (see below).
■Test of cure not necessary if patient becomes asymptomatic