Genitourinary Infections

By Spencer H. Durham, Pharm.D., BCPS, BCIDP

Reviewed by Elizabeth B. Hirsch, Pharm.D., FCCP; Megan Chynoweth, Pharm.D., BCACP, CDCES; and Kenyu Tan, Pharm.D., BCACP,
BCGP, BCPS

LEARNING OBJECTIVES

1. Distinguish the differences between acute cystitis (AC) and pyelonephritis, as well as between uncomplicated and
complicated UTIs.
2. Evaluate the pharmacotherapy options used for UTIs and distinguish between appropriate and inappropriate use.
3. Evaluate recommendations from available clinical practice guidelines related to UTIs.
4. Analyze appropriate selection of empiric treatment options given increased antimicrobial resistance, particularly to the
fluoroquinolones and trimethoprim/sulfamethoxazole.
5. Design a pharmacotherapy treatment plan for patients with AC, pyelonephritis, catheter-associated UTIs, and prostatitis.

INTRODUCTION
ABBREVIATIONS IN THIS CHAPTER
Urinary tract infections are among the most common type of infec-
AC Acute cystitis
tious diseases encountered in the ambulatory care setting. The
ASB Asymptomatic bacteriuria
lifetime incidence of UTIs in female adults is estimated to be as
CA-ASB Catheter-associated
asymptomatic bacteriuria high as 50%–60%, with many women experiencing a recurrent infec-
CAUTI Catheter-associated UTI tion within 1 year (Medina 2019). Urinary tract infections are most
C&S Culture & susceptibility common in adolescents and women of childbearing age. Urinary
tract infections are uncommon in men because of their inherently
cUTI Complicated UTI
longer urethra, making bacterial ascension from the outside the body
MDRO Multidrug-resistant organism
up the urethra much more difficult than in females. However, after
uUTI Uncomplicated UTI
age 65, the incidence of UTIs between males and females is about
Table of other common abbreviations. equal, primarily because of immunosenescence and male-specific
risk factors, such as benign prostatic hypertrophy.

CLASSIFICATION OF GENITOURINARY
INFECTIONS
Urinary tract infection is a broad term that refers to an infection of
any area of the urinary tract, ranging from the urethra to the kidneys.
Table 1 shows the different types of UTIs. Most UTIs occur through
the ascending pathway, by which uropathogens from the perirec-
tal area colonize the urethral opening and ascend up the urethra to
establish an infection in the bladder (acute cystitis [AC]) or transverse
further to infect the kidneys (pyelonephritis). Because of the prox-
imity of the urethra to the perirectal area, most UTIs are caused by
enteric gram-negative organisms. In otherwise healthy women with
AC and pyelonephritis, Escherichia coli accounts for more than 80%
of infections; Klebsiella pneumoniae and Proteus mirabilis account
for most other infections. Gram-positive organisms are unusual
causes, though Staphylococcus saprophyticus can cause infections
in otherwise healthy women. Some infections, such as urethritis,
though technically considered UTIs, are generally caused by sexually

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 7 Genitourinary Infections

transmitted infections and are beyond the scope of this
chapter. The descending or hematogenous pathway of infec- Table 1. Different Types of UTIs
tion occurs when bacteria from another infection site travel
Type of UTI Definition
through the bloodstream to infect the urinary tract; however,
this accounts for less than 5% of all UTIs (Fernandez 2020). Acute cystitis Infection of the urinary bladder (lower
Urinary tract infections can broadly be classified as either UTI) with accompanying localized signs
uncomplicated (uUTIs) or complicated (cUTIs), but this ter- and symptoms of infection such as
increased urinary frequency, dysuria,
minology can be confusing because there is no standard
and nocturia. Usually diagnosed with a
definition for either term. In general, uUTIs occur in premeno-
urine culture showing > 100,000 CFU/
pausal, otherwise healthy women who have no underlying
mL of a pathogenic organism
structural or anatomical anomaly that might predispose them
to a UTI, such as vesicoureteral reflux. Any other type of Pyelonephritis Infection of the kidneys (upper UTI) with
accompanying systemic signs and
patient is generally considered to have a cUTI. This includes
symptoms of infection, such as fever,
male patients, patients with underlying structural/anatomical
flank pain, nausea/vomiting, and chills
abnormalities, and older adults. Urinary tract infections can
also be classified as either lower or upper, depending on the Uncomplicated No standard definition, but generally
exact location of the infection. Acute cystitis is considered UTIs understood to be infections in healthy,
premenopausal women who have no
underlying structural or anatomical
abnormalities
BASELINE KNOWLEDGE STATEMENTS
Complicated No standard definition, but generally
Readers of this chapter are presumed to be familiar UTIs understood to be any infection that falls
with the following: outside the usual understanding of an
uncomplicated infection. Individuals
• Pathophysiology, risk factors, and common
with these infections include, but are
pathogens of UTIs
not limited to, male patients, older
• Common microbiological causes of UTIs
adults, and patients with underlying
• Common antimicrobial agents used in the treat-
structural or anatomical abnormalities
ment of UTIs
of the urinary tract
• Basic principles of antimicrobial stewardship and
antimicrobial resistance Recurrent UTIs ≥ 2 separate, culture-proven episodes of
symptomatic UTI episodes within 6 mo
Table of common laboratory reference values. or ≥ 3 episodes within 1 yr

ADDITIONAL READINGS Information from: Medina M, Castillo-Pino E. An introduction

to the epidemiology and burden of urinary tract infections.
The following free resources have additional back- Ther Adv Urol 2019;11:1756287219832172; Gupta K, Hooton
ground information on this topic: TM, Naber KG, et al. International clinical practice guide-
lines for the treatment of acute uncomplicated cystitis and
• Gupta K, Hooton TM, Naber KG, et al. International
pyelonephritis in women: a 2010 update by the Infectious
clinical practice guidelines for the treatment of
Diseases Society of America and the European Society of
acute uncomplicated cystitis and pyelonephritis in Microbiology and Infectious Diseases. Clin Infect Dis 2011;
women: a 2010 update by the Infectious Diseases 52:e103-e120.
Society of America and the European Society of
Microbiology and Infectious Diseases. Clin Infect
Dis 2011;52:e103-e120.
a lower UTI, whereas pyelonephritis is considered an upper
• Nicolle LE, Gupta K, Bradley SF, et al. Clinical
UTI. A common misconception is that an upper UTI equates
practice guideline for the management of asymp-
tomatic bacteriuria: 2019 update by the Infectious to a cUTI and a lower UTI indicates a uUTI, but the anatomic
Diseases Society of America. Clin Infect Dis location of the infection does not relate to the complexity. For
2019;68:e83-e110. example, a male patient with AC would be considered to have
• Hooton TM, Bradley SF, Cardenas DD, et al. a cUTI, whereas an otherwise healthy female with pyelone-
Diagnosis, prevention, and treatment of catheter- phritis would likely be considered to have an uncomplicated,
associated urinary tract infection in adults: 2009 though potentially severe, infection.
international clinical practice guidelines from the
Infectious Diseases Society of America. Clin Infect
Acute Cystitis
Dis 2010;50:625-63.
Acute cystitis is the most common manifestation of UTIs in
the ambulatory care setting. Signs and symptoms of AC are

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 8 Genitourinary Infections

localized and include dysuria, increased urinary frequency, highly suggestive of infection. The combination of a positive
urgency, and nocturia. In otherwise healthy, premenopausal leukocyte esterase test and a positive nitrite test is highly
women, AC can be diagnosed by signs and symptoms alone. suggestive of a UTI, particularly in a symptomatic patient.
However, confirmatory testing is often achieved through Urine cultures, though considered the “gold standard” for
either a urine dipstick test or a urinalysis. The hallmark indi- diagnosis, are not always performed in the ambulatory care
cation of infection is the presence of WBCs or leukocyte setting to confirm AC because signs and symptoms and uri-
esterases, which are a byproduct of WBCs. The presence nalyses are sufficient for diagnosis. When a urine culture is
of leukocyte esterase is highly sensitive but not specific for performed, greater than 100,000 CFU/mL of a pathogenic
UTIs; leukocyte esterase can be a useful antimicrobial stew- species is considered diagnostic in symptomatic women.
ardship tool because the lack of presence would rule out Table 2 shows different diagnostic measures for UTIs.
infection, and antimicrobial therapy could be avoided (Advani An important area of concern for the ambulatory care
2021). In addition, certain gram-negative bacteria, including pharmacist is distinguishing between patients with asymp-
the three organisms that primarily cause UTIs, reduce nitrates tomatic bacteriuria (ASB) and those experiencing true AC.
into nitrites in the urine, making the presence of nitrites Asymptomatic bacteriuria is the presence of bacteria in the

Table 2. Diagnostic Measures for UTIs

Diagnostic Measure Comments

Signs and symptoms • In otherwise healthy, premenopausal women, signs and symptoms alone are enough to diagnose
a UTI
• Typical signs and symptoms include dysuria, increased urinary frequency, and nocturia
• Signs and symptoms alone should not be used to diagnose pyelonephritis

Urine dipstick testing • Sometimes called a rapid urine test because results are available in ~60 s
• Involves dipping a test strip into a urine sample in the clinic setting without the need to send the
sample to the laboratory; hence, it is useful as a rapid screening tool
• Detects the presence of blood, protein, leukocyte esterase, and nitrites, among other substances
• Does not provide quantitative amounts; only detects the presence of the substances
• Should be performed on a clean-catch urine sample

Urinalysis • Comprehensive urine test that detects the presence of all the substances that a urine dipstick
test does, but provides quantitative amounts
• Also tests for parameters such as specific gravity, presence of epithelial cells, and bacteria,
among others
• Must be performed by a laboratory, so results are not immediately available
• Should only be performed on a clean-catch urine sample and only in symptomatic patients
because inaccurate results can lead to inappropriate diagnosis and antimicrobial prescribing
• Provides more specific information than a urine dipstick test

Urine culture • Considered the gold standard for diagnosing a UTI

• > 100,000 CFU/mL of one or more pathogenic organisms is considered diagnostic in symptomatic
females
• Results are usually available within 48–72 hours to identify a pathogen with antimicrobial
susceptibility results
• Results must be interpreted in conjunction with clinical signs and symptoms of infection
• A positive urine culture in a patient without signs and symptoms of infection would be ASB
• A positive urine culture in a patient with signs and symptoms of infection would be a UTI (either
AC or pyelonephritis)
• Urine cultures should always be obtained in patients with pyelonephritis
• For patients with AC, urine cultures can be performed; however, they are not required because
some recommended empiric therapies would already be complete by the time the culture results
are available

AC = acute cystitis; ASB = asymptomatic bacteriuria.

Information from: Advani SD, Polage CR, Fakih MG. Deconstructing the urinalysis: a novel approach to diagnostic and antimicrobial
stewardship. Antimicrob Steward Healthc Epidemiol 2021;1:e6; Fernandez JM, Coyle EA. Urinary tract infections and prostatitis. In:
DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach, 11th ed. McGraw-Hill, 2020:chap 134.

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 9 Genitourinary Infections

urine without accompanying signs and symptoms of infec- Placement of an indwelling urinary catheter provides
tion. Asymptomatic bacteriuria is diagnosed with a urine a portal of entry for bacteria directly into the urinary tract;
culture showing greater than 100,000 CFU/mL of an organ- also, the catheters themselves can become colonized with
ism and, under most circumstances, is not considered a true bacteria after insertion, which is known as catheter-associ-
infection (Nicolle 2019). The presence of bacteria in the urine ated asymptomatic bacteriuria (CA-ASB). Almost all patients
alone should never be considered diagnostic for a UTI, par- with indwelling catheters will have developed CA-ASB after
ticularly in otherwise healthy, premenopausal women. Often, 1 month, though some patients may develop it much faster.
bacteria may be present in the urine because of a non– The infections of most patients with CA-ASB do not progress
clean-catch urine sample. In addition, the clinical practice to a true CAUTI, but distinguishing between these two con-
guidelines for the treatment of ASB recommend antibiotics ditions is often quite difficult. Treating CA-ASB accounts for
only in limited situations, such as for the treatment of preg- considerable inappropriate antibiotic use. One reason that
nant women and for patients with ASB about to undergo CA-ASB and CAUTIs are difficult to distinguish is that patients
invasive urologic procedures. with CAUTIs may not experience the typical signs and symp-
toms of a UTI. Rather, the signs and symptoms of CAUTIs may
Pyelonephritis include fever, rigors, altered mental status, an acute worsen-
Pyelonephritis occurs when pathogenic bacteria ascend ing of mental status in a patient with baseline altered mental
from the urinary bladder up the ureters and establish infec- status, malaise/lethargy, flank pain, costovertebral angle
tion in the kidneys. Compared with AC, pyelonephritis is tenderness, and pelvic discomfort. In some patients, these
a more severe, systemic infection that can result in severe symptoms may be so subtle that they go unnoticed.
complications, such as bacteremia and sepsis. The signs Using urinalysis results to diagnose a CAUTI is often unre-
and symptoms associated with AC can also occur with pyelo- liable because most patients with indwelling catheters will
nephritis, but more systemic signs and symptoms, such as experience pyuria. Because a catheter is a foreign body,
fever, chills, flank pain, and nausea/vomiting, can also occur WBCs will naturally gravitate to the area, resulting in pyuria.
in some patients with pyelonephritis. Pyelonephritis can be Thus, pyuria should not be used as an indication for antimi-
treated in either the outpatient or inpatient setting, depend- crobial therapy in a patient with an indwelling catheter. In
ing on patient severity. In general, patients with unstable vital addition, patients with a catheter should not be screened for
signs whose infection may be progressing toward sepsis the presence of bacteria in the urine because it will almost
should be admitted for treatment. Severe nausea and vom- always be positive. Catheter-associated ASB is defined by
iting that result in dehydration may also warrant inpatient the presence of greater than 100,000 CFU/mL of at least one
treatment. However, in the absence of these severe signs and pathogenic organism in a single catheter urine specimen in
symptoms, pyelonephritis can be treated in the ambulatory a patient without UTI symptoms. A CAUTI is defined by the
care setting with close monitoring of the patient. Inpatient presence of UTI signs and symptoms plus 1000 CFU/mL of
management is not further discussed in this chapter. Unlike at least one pathogenic organism in a single catheter urine
with AC, urine culture and susceptibility (C&S) testing should specimen. In patients thought to have a CAUTI who have a
always be performed in a patient thought to have pyelonephri- catheter that has been in place for more than 2 weeks, the
tis to ensure correct pharmacotherapy. catheter should be replaced and the urine culture obtained
from the new catheter. This will provide the most accurate
Catheter-Associated UTIs laboratory results and is also necessary for resolution of the
Catheter-associated UTIs (CAUTIs) are most common in infection. Catheter replacement is not required if the catheter
the hospital and long-term care settings, but they are also has been in place less than 2 weeks, but some clinicians may
encountered in the ambulatory care setting in older adults still elect to replace the catheter.
and in patients with certain medical conditions, such as neu-
rogenic bladder. Pathogens of the order Enterobacterales are Prostatitis
the most common cause of CAUTIs, with E. coli being the most Although the prostate gland plays no role in the produc-
commonly identified pathogen; however, it accounts for only tion and voiding of urine, prostatitis is similar to UTIs in
about one-third of cases. Other causative organisms include many ways. Although the pathogenesis of prostatitis is not
Klebsiella, Serratia, Citrobacter, Enterobacter, and Pseudomonas completely understood, the reflux of infected urine into the
spp. In addition, the presence of the catheter predisposes prostate gland is almost certainly involved. As such, the
to gram-positive organisms, such as Staphylococcus aureus, pathogenic organisms associated with UTIs are also asso-
coagulase-negative staphylococci, and Enterococcus spp. ciated with prostatitis, with E. coli accounting for about
Infections in patients with short-term catheters (less than 75% of cases. Prostatitis becomes more common with
30 days) are usually monomicrobial, whereas infections in increased age, and as many as 50% of all men will develop
patients with long-term catheters (30 days or longer) are usu- prostatitis at some point. In addition, prostatitis is classi-
ally polymicrobial. fied as either acute or chronic, which have distinctly different

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 10 Genitourinary Infections

presentations. Acute prostatitis is characterized by the sud- different drug therapies can be used, each with distinct
den onset of fever, chills, localized rectal tenderness, dysuria, advantages and disadvantages. The main pharmacologic
and increased urinary frequency. Chronic prostatitis is char- treatments used in the outpatient setting are discussed in
acterized by much more subtle and nonspecific symptoms, the text that follows.
such as difficulty urinating, perineal pain, low back pain, or
recurrent UTIs. These nonspecific symptoms may make diag- Nitrofurantoin
nosis of chronic prostatitis more difficult. In contrast, acute Nitrofurantoin has many desirable properties conducive to
prostatitis can be diagnosed through signs and symptoms UTI treatment. Nitrofurantoin is reduced by flavoproteins pro-
and the presence of bacteriuria. Culturing prostate fluid is duced by bacteria to reactive metabolites that ultimately result
not generally recommended when acute prostatitis is sus- in inhibition of bacterial protein synthesis, aerobic energy
pected because obtaining the sample would require prostate metabolism, DNA/RNA, and cell wall synthesis. In the urine,
massage, which can result in bacteremia. Obtaining a culture nitrofurantoin has bactericidal activity and is a broad-spec-
can be considered when chronic prostatitis is suspected, but trum agent with in vitro activity against most organisms that
diagnosis is more commonly made because of the diagnosis commonly cause UTIs, including E. coli and Klebsiella, though
of recurrent UTIs with the same organism (Sharp 2010). it is not active against Proteus spp. Furthermore, nitrofuran-
toin is active against some multidrug-resistant gram-negative
UTIs in Special Populations organisms and vancomycin-resistant Enterococcus. Although
If a male younger than 65 years is diagnosed with a UTI, fur- nitrofurantoin is broad spectrum, it does not significantly
ther investigation is necessary to assess for underlying concentrate outside the urinary bladder; thus, normal micro-
anatomical or structural abnormalities that might predispose flora are not exposed to the drug, resulting in a low risk of
to a UTI. There are no specific guidelines or recommendations collateral damage. Collateral damage refers to the ecologi-
for treating male patients, and only limited primary literature cal adverse effects of drug therapy in which broad-spectrum
exists; thus, treatments are usually extrapolated from data drugs affect the normal microflora of humans to a greater
in otherwise healthy females. In general, male patients with degree than narrower-spectrum drugs, resulting in increased
AC are treated for longer durations than their female coun- antimicrobial resistance. Of note, nitrofurantoin does not
terparts, but this is primarily based on clinical experience concentrate well in the kidneys; hence, it is only appropriate
rather than available quality data. However, some evidence for the treatment of AC, not pyelonephritis. Pulmonary fibro-
suggests that shorter courses of therapy are effective. One sis is a concern during long courses of treatment, such as
recent randomized controlled trial showed that ciprofloxacin for UTI prophylaxis, but is not generally a concern with usual
or trimethoprim/sulfamethoxazole for 7 days was noninferior courses of therapy for UTIs.
to 14 days of therapy with respect to symptom resolution 14 Of note, a historical recommendation was that nitrofuran-
days after therapy in men experiencing afebrile UTIs (Drekonja toin was contraindicated in patients with a CrCl less than
2021). Although UTIs are relatively common in older adults, 60 mL/minute/1.73 m2 because the prevailing thought was
available data on treatments are limited; thus, specific guide- that appropriate renal filtration was required for the drug to
lines are unavailable, and like with male patients, treatment concentrate in the urine and that adverse effects would be
options are extrapolated from studies of otherwise healthy higher with decreasing renal function. However, more recent
women. Also similar to male patients, treatment durations studies have shown that nitrofurantoin is both safe and effec-
tend to be longer for older adults. tive in patients with a CrCl greater than 30 mL/minute/1.73 m2.
Pregnant women are at increased risk of experiencing UTIs In 2015, the Beers criteria were updated to reflect this new
secondary to changes in the urinary tract, such as decreased evidence. Pharmacists can play a key role in disseminat-
bladder tone and dilation of the renal pelvis and ureters. ing and educating health care providers regarding this
Because of the serious risks associated with UTIs during recommendation.
pregnancy, such as premature labor and fetal death, preg-
nant women should receive treatment, even in cases of ASB Trimethoprim/Sulfamethoxazole
(Sheiner 2009). In general, the best recommended length of Historically, trimethoprim/sulfamethoxazole has been a
therapy for pregnant women is not known, but they are gener- mainstay in the treatment of UTIs because of its high concen-
ally treated with longer courses of therapy than nonpregnant tration in the urinary bladder and kidneys and reliable activity
women with AC (Ovalle 2001). against the most common bacterial causes of UTIs. However,
this has also led to widespread overuse and misuse of
PHARMACOLOGIC THERAPIES USED trimethoprim/sulfamethoxazole, resulting in increased bac-
IN THE TREATMENT OF UTIS terial resistance of gram-negative organisms to this agent.
Most data for drug therapy used for UTIs are derived from Some areas of the country report such high resistance rates
studies of premenopausal, otherwise healthy women. Several to trimethoprim/sulfamethoxazole that it is no longer a viable
option for empiric treatment.

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 11 Genitourinary Infections

 Trimethoprim/sulfamethoxazole works by interfering β-Lactams
with the bacterial synthesis of folic acid. Although generally Different β-lactam agents, including penicillins, cephalospo-
well tolerated, trimethoprim/sulfamethoxazole induces true rins, and carbapenems, are effective in the treatment of both
allergic reactions in some patients and can increase serum AC and pyelonephritis. Historically, the β-lactams were not
potassium concentrations, particularly when combined with considered first-line treatment for UTIs because they pro-
other drugs that cause the same effect, such as angioten- vide no greater efficacy than nitrofurantoin or trimethoprim/
sin-converting enzyme inhibitors. Because trimethoprim/ sulfamethoxazole. The β-lactams can be associated with
sulfamethoxazole concentrates in areas of the body outside higher rates of adverse effects, particularly GI and immune-
the urinary tract and has a broader spectrum of activity than mediated reactions. The β-lactams are generally prescribed
nitrofurantoin, it has a higher propensity to cause collateral for 3–7 days for AC and 7–10 days for pyelonephritis. The
damage. Despite this, and assuming the pathogen is suscep- propensity of the β-lactams for collateral damage varies by
tible, trimethoprim/sulfamethoxazole is highly efficacious for agent, depending on the spectrum of activity. For example,
treating both AC and pyelonephritis. the third-generation cephalosporins have a higher propensity
than the first-generation agents.
Fosfomycin Because of increased resistance to both trimethoprim/
Fosfomycin is a cell wall synthesis inhibitor with a broad spec- sulfamethoxazole and the fluoroquinolones (see the text
trum of activity against many of the organisms commonly that follows), the β-lactams have become more prominent
associated with UTIs. Fosfomycin is available as an oral pow- treatments for UTIs, particularly given that gram-negative
der that must be mixed with liquid before consumption. A organisms have retained a relatively high susceptibility, though
unique feature of fosfomycin is that it can be administered this may vary widely by location. For the treatment of AC, the
as a one-time dose to treat AC caused by E. coli (Stein 1999). β-lactams are probably best used as an alternative when nitro-
Because fosfomycin does not significantly concentrate in furantoin or trimethoprim/sulfamethoxazole cannot be used.
the kidneys, it should not be used for the treatment of pyelo- However, for the outpatient treatment of pyelonephritis, an
nephritis. Given its broad spectrum of activity and some immediate dose of intravenous or intramuscular ceftriaxone
absorption outside the urinary tract, fosfomycin has a higher has become a mainstay of therapy (because of its prolonged
propensity for collateral damage than nitrofurantoin, though half-life and the ability to administer a single dose in the clinic
probably not as high as trimethoprim/sulfamethoxazole. setting), followed by an oral β-lactam agent.
Although most uropathogens currently retain high suscep-
tibility to fosfomycin, according to epidemiologic studies, Fluoroquinolones
fosfomycin susceptibility is not generally tested for in most The fluoroquinolones are highly effective for both AC and
clinical laboratories because of the currently recommended pyelonephritis when the organism is susceptible. The flu-
methods for testing (i.e., agar and disk diffusion). oroquinolones achieve high concentrations in the urinary
Fosfomycin also has broad coverage against several bladder and kidneys and are bactericidal. Short courses of
multidrug-resistant organisms (MDROs), including vancomy- therapy (3 days) are highly effective for AC, and although
cin-resistant Enterococcus spp. and methicillin-resistant S. longer courses are required for the treatment of pyelonephri-
aureus (MRSA). Although these are uncommon causes of UTIs tis, the fluoroquinolones are considered the drug of choice
in the ambulatory care setting, fosfomycin is useful if one of for pyelonephritis because of their high efficacy. However,
these organisms is confirmed. Perhaps more importantly, these qualities have resulted in widespread misuse of the
fosfomycin also provides activity against extended-spectrum fluoroquinolones, leading to widespread resistance of
β-lactamase–producing organisms, with E. coli and K. pneu- gram-negative organisms. Of the drugs discussed so far,
moniae being two of the most common organisms producing the fluoroquinolones have the highest propensity for collat-
extended-spectrum β-lactamases. Although extended-spec- eral damage because of their very broad spectrum of activity
trum β-lactamase–producing strains are also uncommon in and ability to achieve high concentrations throughout the
the ambulatory care setting, the incidence is increasing and body (Paterson 2004). Consequently, the usefulness of the
will likely continue to increase as uropathogens become more fluoroquinolones for the treatment of UTIs has dramatically
resistant to commonly used treatment agents. Thus, fosfo- decreased. These factors, together with their many potential
mycin may play a more important role in the treatment of adverse effects, support avoidance of the fluoroquinolones
AC in the future. Of note, when using fosfomycin to treat an for AC treatment unless no other options exist. Of note, moxi-
MDRO, there are no specific dosing recommendations, and floxacin is never appropriate for UTI treatment, even if the
several doses are likely required, even when treating AC. In organism was susceptible, because adequate urinary con-
addition, evidence is increasing that one dose of fosfomy- centrations are not achieved after its administration. Several
cin is inferior to nitrofurantoin for the treatment of uUTIs in fluoroquinolones have been studied in clinical trials, though
women; thus, the current single-dose recommendation may ciprofloxacin and levofloxacin are used almost exclusively in
change as more evidence is accumulated (Huttner 2018). clinical practice.

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Aminoglycosides 5 days, should give nitrofurantoin strong consideration as the
Aminoglycosides such as gentamicin and tobramycin preferential agent for the treatment of AC. However, of the
are highly effective in the treatment of UTIs, particularly three first-line therapies, nitrofurantoin requires the longest
pyelonephritis. The aminoglycosides achieve excellent con- length of therapy at 5 days and may not be suitable for all
centrations in the kidneys and have maintained reliable patients, particularly when adherence may be of concern.
activity against gram-negative organisms. Although the ami- Trimethoprim/sulfamethoxazole has historically been the
noglycosides are primarily used in the inpatient setting for the recommendation of choice for the treatment of AC because
treatment of pyelonephritis because of intravenous adminis- of its reliable efficacy when the pathogen is susceptible and
tration, they can also be used for outpatient treatment when was recommended in the original Infectious Diseases Society
administered as an initial one-time dose. If used in this way, of America guidelines. Although the propensity of trimetho-
the aminoglycosides should be dosed as a 24-hour regimen, prim/sulfamethoxazole for collateral damage is greater than
with subsequent doses of a different agent administered that of nitrofurantoin, it is not thought to be as high as that of
orally. This is similar to how ceftriaxone is used in the outpa- the fluoroquinolones or extended-spectrum cephalosporins.
tient treatment of pyelonephritis. Because of their high risk of Trimethoprim/sulfamethoxazole is recommended for 3-day
nephrotoxicity, the aminoglycosides should be avoided in any courses because longer durations have not been shown to
patient with underlying renal dysfunction. However, the risk be more effective than those lasting 3 days. Pharmacists
of nephrotoxicity is low when aminoglycosides are adminis- can play an important role in educating other health care
tered as a one-time initial dose. The aminoglycosides are not providers regarding the length of therapy for trimethoprim/
generally used in the treatment of AC except in limited cir- sulfamethoxazole because clinicians often unnecessarily
cumstances when the infection is caused by an MDRO. prescribe longer durations in practice, even for otherwise
healthy women.
CLINICAL PRACTICE GUIDELINES The main caveat with the use of trimethoprim/sulfame-
Currently, there are three clinical practice guidelines related to thoxazole is that empiric therapy is not recommended when
the treatment of UTIs: (1) treatment of AC and pyelonephritis local resistance rates to uropathogens are 20% or higher.
in premenopausal women (Gupta 2011), (2) treatment of ASB Resistance rates of uropathogens to trimethoprim/sulfame-
(Nicolle 2019), and (3) treatment of CAUTIs (Hooten 2010). As thoxazole are a global concern, and resistance in the United
mentioned earlier, no guidelines exist to guide the treatment States is almost certainly higher now than in 2011 when the
of males, older adults, or other unique patient populations. guidelines were last updated. The European Association of
However, research in these areas is limited. The guidelines Urology no longer recommends trimethoprim/sulfamethox-
for the treatment of AC and pyelonephritis are being updated, azole as a first-line therapy for AC because of high resistance
given that they were last published in 2011, and some recom- rates in Europe. In addition, and unlike in the health sys-
mendations are likely outdated, particularly as they pertain to tem setting where antibiograms are often used, clinicians
antimicrobial resistance. Because ASB should not be treated in the ambulatory care setting may not have access to local
except in very limited circumstances (pregnancy and before resistance patterns in the community, making the choice
urologic procedures), it is not discussed further. of trimethoprim/sulfamethoxazole uncertain. When local
resistance patterns are unknown, trimethoprim/sulfame-
AC in Otherwise Healthy, thoxazole should generally be avoided. This combination of
Premenopausal Women factors makes trimethoprim/sulfamethoxazole a less desir-
Three agents are guideline recommended first line for the able empiric option for the treatment of AC than historically
treatment of AC: nitrofurantoin, trimethoprim/sulfamethoxaz- recommended. However, when local uropathogen resistance
ole, and fosfomycin (Gupta 2011). Each treatment is given an is known to be less than 20% or if the infecting organism is
equal rating of evidence but differs with respect to dosing, known to be susceptible, trimethoprim/sulfamethoxazole can
frequency, and therapy duration. Pivmecillinam is also rec- be an appropriate treatment.
ommended as a first-line therapy, but its availability is limited The final first-line recommended agent is fosfomycin dosed
to a few European countries, and it is not discussed further. as 3 g (one packet) orally as a one-time dose. The possibility
The β-lactams and fluoroquinolones are recommended as of administering a one-time dose may be very attractive to
second-line therapies. Table 3 lists the antimicrobials used both patients and prescribers, particularly when adherence is
in the treatment of AC and summarizes the information for a concern, given that the dose can be administered directly in
each. the clinic setting. However, the cost of fosfomycin is usually
Of the three recommended first-line therapies, nitrofuran- higher than that of other first-line options, and fosfomycin is
toin poses the least risk of collateral damage and is therefore often not covered by insurance formularies, which may limit
least likely to induce the development of antimicrobial resis- its use. In addition, although the one-time dose is effective,
tance. This, combined with its reliable efficacy and favorable fosfomycin does not appear to be as effective as trimetho-
safety and tolerability profile, particularly when used for only prim/sulfamethoxazole and nitrofurantoin in the treatment

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 13 Genitourinary Infections

 Table 3. Antimicrobials Used in the Empiric Treatment of AC

Antimicrobial Dose Frequency Duration Comments

First-line Nitrofurantoin 100 mg Twice daily 5 days • Lowest risk of collateral

agents damage
• Well tolerated

TMP/SMX 1 double-strength Twice daily 3 days • Only use empirically

tablet (160 mg/ when local uropathogen
800 mg) resistance is < 20%
• Avoid use if local resistance
rates are unknown

Fosfomycin 3 g (one packet) Once N/A • Useful for patients with

adherence issues, but the
single dose may be less
effective and is expensive
• Useful for MDROs, but
treatment requires several
doses

Second- Fluoroquinolones: 250 mg immediate Twice daily for 3 days • Highly effective when the
line Ciprofloxacin release or 500 mg the immediate organism is susceptible, but
agents extended release release, once resistance is dramatically
daily for the increasing
extended release • Associated with rare but
serious adverse effects
Levofloxacin 250 mg Once daily • Highest risk of collateral
damage
• Use only when a first-line
agent cannot be used

β-Lactams: Varies depending Varies depending 3–7 days • Slightly less effective than
Various agents are used, on drug selected on drug selected first-line agents, but high
including amoxicillin/ resistance to other drugs
clavulanate, cephalexin, often warrants use
cefaclor, cefdinir, and
cefpodoxime

MDRO = multidrug-resistant organism; N/A = not applicable; TMP/SMX = trimethoprim/sulfamethoxazole.

Information from: Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute
uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the
European Society of Microbiology and Infectious Diseases. Clin Infect Dis 2011;52:e103-e120.

of AC. A recent study showed that nitrofurantoin was signifi- achieved clinical resolution at day 28; in the fosfomycin
cantly more likely to result in both microbiologic and clinical group, 139 of 241 patients (58%) achieved clinical resolution
cure than fosfomycin (Huttner 2018). This was a multina- at day 28 (p=0.004). Microbiologic cure occurred in 74% of
tional, open-label, analyst-blinded, randomized controlled trial patients in the nitrofurantoin group and 63% in the fosfomy-
with an objective to compare the clinical and microbiologic cin group (p=0.04). The results of this trial call into question
efficacy of nitrofurantoin and fosfomycin in women with whether fosfomycin should remain a first-line treatment for
uncomplicated cystitis. Participants were randomized in a 1:1 AC or should instead be relegated to second-line use when
fashion to receive either nitrofurantoin (100 mg orally three nitrofurantoin cannot be used. Of note, this trial used nitrofu-
times daily for 5 days; n=255) or fosfomycin (3 g orally as a rantoin at a higher daily dose (100 mg orally three times daily)
single dose; n=258), with follow-up occurring at days 14 and than currently recommended (100 mg orally twice daily);
28 after therapy completion for clinical evaluation and urine thus, the lower recommended dose should be compared with
culture collection. A total of 475 patients completed the single-dose fosfomycin in a clinical trial to more accurately
trial. In the nitrofurantoin group, 171 of 244 patients (70%) compare the efficacy with what is done in clinical practice.

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 14 Genitourinary Infections

Given the results of this trial, a strong case can be made for being used for the treatment of AC because of increased anti-
the preferential use of nitrofurantoin over fosfomycin for the microbial resistance to other agents. When β-lactams must
treatment of AC. Despite its lower efficacy, fosfomycin is still be used, agents with a narrower spectrum of activity and a
useful for the treatment of AC in certain circumstances, par- lower risk of collateral damage, such as first-generation ceph-
ticularly when adherence is a concern and for cases caused alosporins, are preferable, though this may not always be
by MDROs. possible when therapy is empiric.
The oral β-lactams are recommended second line for the The fluoroquinolones have extensively been studied for
treatment of AC. The β-lactams specifically recommended the treatment of AC and show high efficacy when the patho-
by the clinical practice guidelines include amoxicillin/clavu- gen is susceptible. Because 3 days of therapy is highly
lanate, cefdinir, cefaclor, and cefpodoxime, but the guidelines effective, longer durations are not needed when treating AC.
note that other agents, such as cephalexin, may also be Similar to the extended-spectrum β-lactams, fluoroquino-
appropriate. Amoxicillin and ampicillin, though historically lone overuse has been associated with the development of
used for the treatment of AC, are no longer recommended as MDROs and C. difficile infections. Fluoroquinolone use has
empiric or targeted therapy because of widespread resistance also been associated with higher rates of MRSA infections.
among uropathogens and the overall poor efficacy of these The fluoroquinolones also have several boxed warnings for
agents. The recommended therapy duration for a β-lactam rare but serious adverse drug reactions, such as tendon rup-
is 3–7 days. However, because studies of these agents used ture, neurologic problems, and aortic dissection. In 2016, the
different therapy durations, the choice of duration may vary FDA updated the safety information for the fluoroquinolones
from clinician to clinician. In addition, no particular β-lactam to note that the risk of adverse effects outweighs the benefits
is preferred to another; thus, the choice of which to use is also in patients with certain uncomplicated infections, includ-
based on clinician preference, patient-specific factors (e.g., ing AC (FDA 2016). Given these issues, the fluoroquinolones
allergies), and local resistance patterns, if known. should only be used for the treatment of AC when no other
The β-lactams should only be used for the treatment of AC options are available.
when one of the first-line options is not available, because
of several factors. The use of broad-spectrum β-lactams, Pyelonephritis in Otherwise Healthy,
particularly the cephalosporins, is associated with a high Premenopausal Women
degree of collateral damage, including the emergence of The clinical practice guidelines recommend several options
extended-spectrum β-lactamase–producing organisms and for the outpatient treatment of pyelonephritis: the fluoro-
the development of Clostridioides difficile infections, among quinolones, trimethoprim/sulfamethoxazole, the β-lactams,
others. In addition, the β-lactams are generally considered to and the aminoglycosides. The current guidelines heavily rec-
have lower efficacy for the treatment of AC, though clinical tri- ommend the fluoroquinolones for pyelonephritis treatment
als directly comparing the β-lactams with all other first-line because of their high efficacy when the pathogen is suscep-
agents are lacking. One clinical trial compared cefpodoxime tible. However, like with the treatment of AC, antimicrobial
100 mg orally twice daily for 3 days with trimethoprim/sul- resistance with the fluoroquinolones is of increasing concern.
famethoxazole 160/800 mg orally twice daily for 3 days. On Selection of an appropriate empiric antibiotic for pyelonephri-
days 4–7 after completion of therapy, 100% of women who tis is particularly important because of the systemic nature
received trimethoprim/sulfamethoxazole and 98% of women of infection and the probability of progression if not appro-
who received cefpodoxime achieved both clinical and micro- priately treated. As such, the clinical practice guidelines
biological cure, though the small sample size (n=133) limited recommend empiric fluoroquinolone use only when local flu-
the statistical power to detect differences between groups oroquinolone resistance of uropathogens is less than 10%. In
(Kavatha 2003). However, studies that have compared the such situations of low resistance, three treatment options are
β-lactams with the fluoroquinolones generally show lower preferred: ciprofloxacin 500 mg orally twice daily for 7 days,
efficacy for the β-lactams. One study compared amoxicil- with or without an initial intravenous dose of ciprofloxacin
lin/clavulanate 500/125 mg orally twice daily for 3 days 400 mg; ciprofloxacin 1000 mg extended release orally once
with ciprofloxacin 250 mg orally twice daily for 3 days. After daily for 7 days; or levofloxacin 750 mg orally once daily for
4 months of follow-up, 58% of women in the amoxicillin/ 5 days. These regimens are derived from clinical trials that
clavulanate group experienced clinical cure compared with showed higher efficacy with the fluoroquinolones than with
77% of women in the ciprofloxacin group (p<0.001) (Hooton trimethoprim/sulfamethoxazole and the cephalosporins. The
2005). One possible explanation for the decreased efficacy oral fluoroquinolones should be considered the treatment of
of the β-lactams is that they show lower rates of eradication choice for the outpatient treatment of pyelonephritis when
of uropathogens from the vaginal canal, and the persistence the local uropathogen resistance is less than 10%.
of these pathogens in the vaginal reservoir has been postu- However, many areas of the country and the world have
lated as a mechanism of infection. Of note, however, despite uropathogen resistance well exceeding 10%. In such cases
their potentially lower efficacy, the β-lactams are increasingly or when local resistance patterns are unknown, several

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 15 Genitourinary Infections

alternative treatments exist. Alternative treatments involve intravenous route is not possible, but again, data are limited
either a one-time intravenous dose of ceftriaxone 1 g or to support this practice.
a consolidated 24-hour dose of an aminoglycoside (e.g., Other options in situations of high local fluoroquinolone
5–7 mg/kg of either gentamicin or tobramycin), followed by resistance include trimethoprim/sulfamethoxazole and the
an oral fluoroquinolone. There is often confusion among oral β-lactams. If either of these options is selected as empiric
clinicians regarding why the fluoroquinolone is given at all therapy, a one-time dose of ceftriaxone or a consolidated ami-
when fluoroquinolone resistance is of concern. The rationale noglycoside should always be administered to help ensure
is that because the fluoroquinolones are the most effica- appropriate empiric coverage until C&S results are avail-
cious agents for use when the pathogen is susceptible, the able. As with the treatment of AC, antimicrobial resistance
long-acting parenteral agent should provide coverage until to trimethoprim/sulfamethoxazole is of increasing clinical
C&S results are available, but the fluoroquinolone would concern, so empiric use should ideally be avoided; however,
already be initiated in the patient should the pathogen be sus- trimethoprim/sulfamethoxazole is highly efficacious when
ceptible. Some experts recommend continuing the parenteral the pathogen is susceptible. The recommended dose and
agent until C&S results are available, but this approach has duration of trimethoprim/sulfamethoxazole for the treatment
little evidence and may not be feasible in the outpatient set- of pyelonephritis is 1 double-strength tablet orally twice
ting. In addition, intramuscular injections can be used if the daily for 14 days; unlike with AC, data with pyelonephritis are

Patient Care Scenario

A 27-year-old woman presents to the primary care clinic she has presented with a UTI. The patient was success-
with concerns of burning during urination and need- fully treated both prior times with cephalexin 250 mg
ing to get up several times a night to urinate for the past orally every 6 hours for 7 days, though she claims to have
2 nights. Her vital signs in the clinic include tempera- missed several doses during each treatment. She has no
ture 97.9°F, blood pressure 114/78 mm Hg, heart rate known drug allergies. The pharmacist does not know the
72 beats/minute, and respiratory rate 12 breaths/minute. local resistance rates for area uropathogens. What would
A urine dipstick test is positive for both leukocyte ester- be the most appropriate treatment for the patient at this
ase and nitrites. The provider on duty diagnoses AC and time? Does the patient require continuous prophylaxis for
asks for the pharmacist’s recommendation for the most UTIs?
appropriate antibiotic. This is the third time this year

ANSWER
This patient presents with uncomplicated AC, given that Trimethoprim/sulfamethoxazole would not be appropri-
she is an otherwise healthy, premenopausal woman with ate in this scenario because local resistance patterns are
classic signs and symptoms of AC. The urine dipstick unknown; hence, there is no way to know whether resis-
test is positive for leukocyte esterase and nitrites, indi- tance to trimethoprim/sulfamethoxazole is less than 20%.
cating she is experiencing a UTI. She has no systemic The patient could likely receive either nitrofurantoin or
signs or symptoms, and her vital signs are normal; hence, fosfomycin, with either being appropriate for her. However,
pyelonephritis is highly unlikely. The patient is experi- because she appears to have had adherence issues in the
encing a recurrent UTI because this is the third time in past, fosfomycin might be preferred because it is a one-
1 year she has been diagnosed with a UTI. Because of time dose, even though its efficacy may be lower than that
her current infection, she must receive treatment for it. of nitrofurantoin. Although the patient previously received
Although urine cultures are not required for most women an oral β-lactam, this was likely inappropriate because
experiencing AC, a culture would be appropriate for this she is able to receive a first-line agent; hence, there is
patient because this is a recurrent infection, and a cul- no reason to prescribe an oral β-lactam again. Regarding
ture result might help guide future empiric therapy if she whether the patient should receive prophylaxis for future
has a subsequent infection. Even in patients with recur- infections, she meets the criteria to receive it, given that
rent infections, the recommendations for treatment she is experiencing recurrent UTIs. However, this decision
are generally the same as for someone experiencing an is best made using shared clinical decision-making with
initial infection, meaning the first-line treatment is nitro- her primary provider.
furantoin, trimethoprim/sulfamethoxazole, or fosfomycin.

1. Advani SD, Polage CR, Fakih MG. Deconstructing the urinalysis: a novel approach to diagnostic and antimicrobial stewardship.
Antimicrob Steward Healthc Epidemiol 2021;1:e6.7.
2. Anger J, Lee U, Ackerman AL, et al. Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline. J Urol
2019;202:282-9.
3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and
pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society of Microbiology and
Infectious Diseases. Clin Infect Dis 2011;52:e103-e120.

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 16 Genitourinary Infections

limited to support shorter therapy durations with trimetho- be considered to increase the likelihood of susceptibility.
prim/sulfamethoxazole. The oral β-lactams are also not Figure 1 is an algorithm for the treatment of pyelonephritis.
preferred for empiric therapy because of their lower efficacy
compared with the fluoroquinolones, but high antimicrobial CAUTI Guidelines
resistance to other agents sometimes necessitates their use. The clinical practice guidelines for the treatment of CAUTIs
The guidelines do not recommend any specific oral β-lact- were last updated in 2009 (Hooton 2010), and at the time
ams for the treatment of pyelonephritis. However, when being of writing this chapter, were not being updated. Most of
used as empiric therapy, broader-spectrum agents, such as the guidelines focus on catheter care and other activi-
second- or third-generation cephalosporins, should likely ties for which pharmacists are unlikely to have significant

Signs and symptoms

consistent with pyelonephritis

Obtain urinalysis and

urine culture

Is uropathogen resistance to the

No or
Yes fluoroquinolones in the
unknown
area < 10%?

Select one of the following treatments: Select one of the following as the initial
treatment:
• Ciprofloxacin 500 mg
PO BID × 7 days • Ceftriaxone 1 g IV/IM once
• Ciprofloxacin 1000 mg • Consolidated 24-hr dosed
PO once daily extended aminoglycoside IV once
release × 7 days
• Levofloxacin 750 mg
PO once daily × 5 days
After initial IV/IM treatment, select one
*Can consider one of the following as of the following regimens on the basis
initial treatment, followed by one of clinical judgment:
of the preferred oral options above:
• Ciprofloxacin 500 mg PO
BID × 7 days
• Ciprofloxacin 400 mg IV once
• Ciprofloxacin 1000 mg PO
• Ceftriaxone 1 g IV/IM once once daily extended release × 7 days
• Consolidated 24-hr dosed • Levofloxacin 750 mg PO
aminoglycoside IV once once daily × 5 days
• TMP/SMX 1 DS tablet PO
BID for 14 days
• Oral β-lactam for 10–14 days

Figure 1. Pyelonephritis treatment algorithm for the non-hospitalized patient.

BID = twice daily; DS = double-strength; IM = intramuscular(ly); IV = intravenous(ly); PO = oral(ly); TMP/SMX = trimethoprim/
sulfamethoxazole.
Information from: Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute
uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the
European Society of Microbiology and Infectious Diseases. Clin Infect Dis 2011;52:e103-e120.

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 17 Genitourinary Infections

involvement. Recommendations for the use of specific anti- at least 2 weeks, and treatment must often be extended to
microbials are not provided because of the very limited data 4 weeks if patients are slow to show clinical improvement.
from clinical trials. Selection of an empiric antibiotic should Chronic prostatitis is treated for a longer duration, usually
ideally be guided by local antimicrobial resistance informa- 6–8 weeks, but treatment may require up to 12 weeks in some
tion. Possible empiric options include, but are not limited to, cases (Murphy 2009).
all of the antimicrobials described earlier for the treatment
of AC. Urine C&S testing should always be performed when RECOMMENDATIONS FOR SPECIAL
treating a CAUTI to guide ultimate antimicrobial therapy POPULATIONS
(Hooton 2010). As mentioned earlier, well-designed clinical trials for patient
The CAUTI guidelines provide some specific guidance populations that do not fall into the category of otherwise
on therapy duration. Most patients who have prompt reso- healthy, premenopausal women are lacking; thus, no spe-
lution of symptoms after starting antimicrobial therapy can cific treatment guidelines or recommendations are available.
be treated for 7 days. In those who have a delayed response, For male patients who experience a UTI, treatment should
10–14 days is more appropriate. Because no specific defi- be provided, but the underlying cause of the UTI should also
nition of what constitutes a prompt or delayed response is be thoroughly investigated because the cause could be an
provided, clinicians must use their judgment on a case-by- underlying structural or anatomical abnormality. In gen-
case basis. According to the results of one trial, a 5-day eral, the same drug therapies for healthy females can apply
course of levofloxacin may be appropriate for patients who to both male patients and older adults. Other recommenda-
are not severely ill (Peterson 2008). Women younger than 65 tions likely apply as well. For example, if the patient resides
who develop a CAUTI without upper urinary tract symptoms in an area where uropathogen resistance to trimethoprim/
after the catheter has been removed can be treated with a sulfamethoxazole is greater than 20%, trimethoprim/sulfa-
3-day antimicrobial regimen. methoxazole should not be used empirically. In addition, the
fluoroquinolones should be avoided unless no other options
PROSTATITIS TREATMENT exist. Male patients and older adults with a suspected UTI
RECOMMENDATIONS should undergo C&S testing to help guide antimicrobial ther-
No clinical practice guidelines for the treatment of pros- apy. Traditionally, male patients and older adults have been
tatitis exist, likely because of the scarcity of clinical trials treated with longer courses of therapy than healthy females,
related to prostatitis treatment. The antimicrobial agents that though exact durations are based on clinician preference and
penetrate and concentrate well in prostatic tissue are the lack evidence to support longer courses, and a recent trial
fluoroquinolones, followed closely by trimethoprim/sulfame- showed that 7 days of therapy was noninferior to 14 days in
thoxazole (Wagenlehner 2006). Thus, the fluoroquinolones men (Drekonja 2021).
and trimethoprim/sulfamethoxazole are generally consid- Pregnant women should only receive drugs that are gen-
ered the treatments of choice for prostatitis (Lipsky 2010). Of erally considered safe in pregnancy. The β-lactams are
interest, sulfamethoxazole penetrates poorly into prostatic considered safe and have historically been the drugs of
tissue, and trimethoprim alone can be used for treatment. choice for the treatment of UTIs in pregnancy. Nitrofurantoin
However, with increased antimicrobial resistance to the flu- is considered safe until the last 30 days of pregnancy, when
oroquinolones and trimethoprim/sulfamethoxazole, other it should be avoided because of an increased risk of neona-
options are needed. Although alternative options have less tal jaundice. Fosfomycin crosses the placenta but appears
evidence, they include nitrofurantoin, amoxicillin/clavula- to be safe. However, because of less clinical experience than
nate, and cephalosporins such as cephalexin, cefuroxime, or other drugs, fosfomycin should be reserved as an alternative
cefixime. Clinicians must use their judgment when selecting therapy to the β-lactams or nitrofurantoin. The fluoroquino-
an appropriate empiric agent and consider patient-specific lones can inhibit cartilage and bone development, and
factors and local antimicrobial resistance patterns, if known. trimethoprim/sulfamethoxazole is associated with congeni-
Given that trimethoprim/sulfamethoxazole and the fluoro- tal malformations and an increased risk of kernicterus; hence,
quinolones concentrate best in prostatic fluid, they should these drugs should be avoided.
be considered as first-line agents unless antimicrobial resis-
tance is likely or suspected. Urine C&S results can help guide TREATMENT OF RECURRENT UTIS
the selection of a targeted antibiotic, so urine cultures should Recurrent UTIs are common in the ambulatory care setting.
be obtained in all patients when prostatitis is suspected. Around 20%–40% of otherwise healthy women who expe-
Although no drug dosing recommendations exist specifi- rience one episode of AC are likely to experience another,
cally for prostatitis, the upper end of the dosing range for the and 25%–50% of these patients will experience subsequent
chosen drug should be used to ensure adequate penetration recurrent episodes. A recurrent UTI is defined as two sep-
into prostatic tissue. Acute prostatitis should be treated for arate, culture-proven episodes of symptomatic AC within

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 18 Genitourinary Infections

6 months, or three episodes within 1 year. In 2019, the of which antimicrobial to prescribe for prophylaxis should be
American Urological Association, the Canadian Urological based on factors such as previous C&S results and local resis-
Association, and the Society of Urodynamics, Female Pelvic tance patterns as well as patient-specific factors. The most
Medicine & Urogenital Reconstruction released the first clin- evidence from clinical trials appears to be with nitrofuran-
ical practice guidelines for the management of recurrent toin. Strong consideration should be given for nitrofurantoin
uUTIs in women (Anger 2019). The guidelines note that the because of the low risk of collateral damage and tolerability.
treatment for recurrent UTIs should not generally be different However, with nitrofurantoin, pulmonary and hepatic toxicities
from that for a first incident, and current first-line therapy of can occur and are more common with prolonged use; thus, a
nitrofurantoin, trimethoprim/sulfamethoxazole, and fosfomy- different prophylactic agent should likely be prescribed for
cin should be used depending on local resistance patterns. patients with underlying chronic lung and liver problems. The
Unlike a first episode of a UTI, cultures should be performed fluoroquinolones should not be used for prophylaxis because
before initiating antimicrobial therapy when a recurrent UTI of the risk of high resistance, the high propensity for collat-
is suspected. Shared clinical decision-making can be used eral damage, and the risk of adverse effects. The duration of
to determine whether antimicrobial therapy can be deferred antimicrobial prophylaxis varies but is typically 6–12 months.
until urine C&S results have returned to decrease the use of However, after discontinuing prophylaxis, recurrent UTIs
inappropriate antimicrobials. If antimicrobial therapy cannot resume for most women. For this reason, some women con-
be delayed until C&S results have returned, selection of an tinue prophylaxis for years, though there is little evidence for
empiric antimicrobial should be based on prior C&S results this practice and the effect on antimicrobial resistance is
and local resistance patterns. unknown. In practice, women receiving prophylaxis should
Under certain circumstances, antimicrobial prophylaxis be assessed and monitored every few months for efficacy
may be initiated to prevent recurrent UTIs. The decision to ini- and the need for continued prophylaxis. Trial discontinua-
tiate prophylaxis is complex, with consideration given to the tions of prophylaxis can be tried, with prophylaxis reinitiated
benefits to the patient of preventing recurrences while bal- if UTIs recur. For women who experience postcoital UTIs, sin-
ancing the risks of increased antimicrobial resistance. No gle-dose antimicrobial prophylaxis before or after intercourse
specific recommendation is made for when to initiate pro- can help prevent infections. Intermittent dosing of these anti-
phylaxis, so the decision must be shared between the patient microbials is associated with fewer adverse effects than
and the clinician. Many different antimicrobials and regimens continual prophylactic or treatment courses. See Table 4 for
have been evaluated for prophylaxis (Table 4), and the guide- antimicrobial options.
lines do not recommend one agent over another. The choice Finally, non-antimicrobials for preventing recurrent UTIs
can be considered. Non-antimicrobials have many advan-
tages, particularly from an antimicrobial stewardship
Table 4. Oral Antimicrobials Used for Prophylaxis in standpoint. Cranberry products have long been touted as a
Recurrent UTIs measure to prevent UTIs, for which several randomized con-
trolled trials have been conducted in recent years. These
Pre- or Postcoital trials have used a variety of cranberry formulations, including
Continuous Prophylaxis Prophylaxisa juices, cocktails, and tablets, and several trials have shown
• Trimethoprim 100 mg once • TMP/SMX positive benefits with the cranberry products. Currently, evi-
daily 40 mg/200 mg dence is insufficient to recommend a specific product or
• TMP/SMX 40 mg/200 mg (½ single-strength formulation over another, but any formulation that a patient
(½ single-strength tablet) once tablet) can tolerate can be offered as a prophylactic measure. Few
daily • TMP/SMX 80
risks are associated with cranberry products; however, juices
• TMP/SMX 40 mg/200 mg mg/400 mg (single-
(½ single-strength tablet) strength tablet)
may be high in sugar content, so caution should be used in
three times per week • Nitrofurantoin patients with diabetes. Another option that can be consid-
• Nitrofurantoin 50 mg daily 50 mg ered in peri- and postmenopausal women is local vaginal
• Nitrofurantoin 100 mg daily • Nitrofurantoin estrogen therapy, such as creams, which is associated with a
• Cephalexin 125 mg once daily 100 mg reduction in recurrent UTIs. Vaginal estrogen therapy is also
• Cephalexin 250 mg once daily • Cephalexin 250 mg extremely safe, with minimal systemic absorption. Different
• Fosfomycin 3 g every 10 days
formulations of vaginal estrogen products are available, and
no preference is given to one product over another.
a
Patients should take a single dose either immediately
before or immediately after sexual intercourse.
CONCLUSION
Information from: Anger J, Lee U, Ackerman AL, et al.
Recurrent uncomplicated urinary tract infections in Urinary tract infections are a common reason for receipt of
women: AUA/CUA/SUFU guideline. J Urol 2019;202:282-9. antimicrobial therapy in the ambulatory care setting. There

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 19 Genitourinary Infections

are several different types of UTIs, of which AC and pyelo- but they do not recommend specific antimicrobial therapy;
nephritis are the most common. The treatment of UTIs, instead, empiric therapy should be based on local suscepti-
including prostatitis, is becoming more challenging because bility patterns. Because of a lack of well-designed controlled
of increased antimicrobial resistance in uropathogens to trials, guidelines are not available for special populations,
drugs that have traditionally been used as recommended such as older adults and males. However, these patients can
treatments (e.g., trimethoprim/sulfamethoxazole and the flu- be treated similarly to women, but with longer courses of ther-
oroquinolones). Patients with ASB do not generally require apy. Pharmacists play an important role in the management
antimicrobial therapy except in certain limited situations. of UTIs and can educate other health care providers about
Clinical practice guidelines for the treatment of AC and pyelo- appropriate treatment. To provide appropriate treatment,
nephritis in otherwise healthy women are available, but they pharmacists must be familiar with the local resistance pat-
are outdated because of increased global antimicrobial resis- terns of uropathogens.
tance. However, these guidelines are currently being updated
and may be released in 2022, though the exact date is uncer- REFERENCES
tain. Guidelines are also available for the treatment of CAUTIs, Advani SD, Polage CR, Fakih MG. Deconstructing the urinal-
ysis: a novel approach to diagnostic and antimicrobial
stewardship. Antimicrob Steward Healthc Epidemiol
Practice Points 2021;1:e6.
Pharmacists working in the ambulatory care setting
often encounter patients requiring treatment for UTIs. Anger J, Lee U, Ackerman AL, et al. Recurrent uncomplicated
Increased antimicrobial resistance among uropatho- urinary tract infections in women: AUA/CUA/SUFU guide-
gens to agents once commonly used for UTI treatment, line. J Urol 2019;202:282-9.
particularly trimethoprim/sulfamethoxazole and the
Drekonja DM, Trautner B, Amundson C, et al. Effect of 7 vs
fluoroquinolones, has made treatment more challeng-
14 days of antibiotic therapy on resolution of symptoms
ing. Pharmacists must be familiar with local resistance
among afebrile men with urinary tract infection: a random-
patterns in order to treat these infections appropriately.
ized clinical trial. JAMA 2021;326:324-31.
• Pharmacists must be able to distinguish between ASB and
AC to know when antimicrobial therapy is indicated. Fernandez JM, Coyle EA. Urinary tract infections and
• For the treatment of AC, first-line agents for empiric thera- prostatitis. In: DiPiro JT, Talbert RL, Yee GC, et al., eds.
py are nitrofurantoin, trimethoprim/sulfamethoxazole, and Pharmacotherapy: A Pathophysiologic Approach, 11th ed.
fosfomycin. McGraw-Hill, 2020:chap 134.
• Trimethoprim/sulfamethoxazole should not be used as
empiric therapy for AC if local uropathogen resistance is U.S. Food and Drug Administration (FDA). FDA Updates
greater than 20%. Warnings for Fluoroquinolone Antibiotics. July 26, 2016.
• The β-lactams and fluoroquinolones can be used as alter- Available at https://www.fda.gov/news-events/press-
native agents for the treatment of AC, but only if use of a announcements/fda-updates-warnings-fluoroquinolone-
first-line agent is not possible. antibiotics.
• The drugs of choice to treat pyelonephritis are the fluoro-
Gupta K, Hooton TM, Naber KG, et al. International clinical
quinolones because of their highly improved efficacy when
practice guidelines for the treatment of acute uncom-
the pathogen is susceptible. However, high resistance rates
now limit their use.
plicated cystitis and pyelonephritis in women: a 2010
• In areas where local uropathogen resistance to the fluo-
update by the Infectious Diseases Society of America
roquinolones is greater than 10%, a one-time dose of ceftri- and the European Society of Microbiology and Infectious
axone or a consolidated 24-hour aminoglycoside should Diseases. Clin Infect Dis 2011;52:e103-e120.
be administered first, followed by an oral fluoroquinolone. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, pre-
Trimethoprim/sulfamethoxazole or an oral β-lactam can be vention, and treatment of catheter-associated urinary
used in place of fluoroquinolones.
tract infection in adults: 2009 international clinical prac-
• Empiric treatment of CAUTIs should be based on local sus-
tice guidelines from the Infectious Diseases Society of
ceptibility data, and pharmacists should ensure the patient
America. Clin Infect Dis 2010;50:625-63.
is experiencing a true CAUTI and not a CA-ASB.
• Trimethoprim/sulfamethoxazole and the fluoroquinolones Hooton TM, Scholes D, Gupta K, et al. Amoxicillin-
concentrate well in prostatic tissue and should be the clavulanate vs ciprofloxacin for the treatment of
drugs of choice for the treatment of prostatitis, but high uncomplicated cystitis in women: a randomized trial.
resistance may limit their use. The oral β-lactams or nitro- JAMA 2005;293:949-55.
furantoin can be used as an alternative.
• UTIs in men and older adults are generally treated similarly Huttner A, Kowalczyk A, Turjeman A, et al. Effect of 5-day
to infections in women, but longer treatment courses may nitrofurantoin vs single-dose fosfomycin on clinical res-
be required. olution of uncomplicated lower urinary tract infection in
• Women who experience recurrent UTIs can use shared clin- women: a randomized clinical trial. JAMA 2018;319:1781-9.
ical decision-making to determine whether antimicrobial
prophylaxis is appropriate. Kavatha D, Giamarellou H, Alexiou Z, et al. Cefpodoxime-
proxetil versus trimethoprim-sulfamethoxazole for

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 20 Genitourinary Infections

 short-term therapy of uncomplicated acute cystitis in Peterson J, Kaul S, Khashab M, et al. A double-blind, ran-
women. Antimicrob Agents Chemother 2003;47:897-900. domized comparison of levofloxacin 750 mg once-daily for
five days with ciprofloxacin 400/500 mg twice-daily for 10
Lipsky BA, Byren I, Hoey CT. Treatment of bacterial prostati- days for the treatment of complicated urinary tract infec-
tis. Clin Infect Dis 2010;50:1641-52. tions and acute pyelonephritis. Urology 2008;71:17-22.
Medina M, Castillo-Pino E. An introduction to the epidemiol- Sharp VJ, Takacs EB, Powell CR. Prostatitis: diagnosis and
ogy and burden of urinary tract infections. Ther Adv Urol treatment. Am Fam Physician 2010;82:397-406.
2019;11:1756287219832172.
Sheiner E, Mazor-Drey E, Levy A. Asymptomatic bacteri-
Murphy AB, Macejko A, Taylor A, et al. Chronic prostatitis: uria during pregnancy. J Matern Fetal Neonatal Med
management strategies. Drugs 2009;69:71-84. 2009;22:423-7.
Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice Stein GE. Comparison of single-dose fosfomycin and a 7-day
guideline for the management of asymptomatic bacteri- course of nitrofurantoin in female patients with uncompli-
uria: 2019 update by the Infectious Diseases Society of cated urinary tract infection. Clin Ther 1999;21:1864-72.
America. Clin Infect Dis 2019;68:e83-e110.
Wagenlehner FM, Naber KG. Current challenges in the
Ovalle A, Levancini M. Urinary tract infections in pregnancy. treatment of complicated urinary tract infections and
Curr Opin Urol 2001;11:55-9. prostatitis. Clin Microbiol Infect 2006;12(suppl 3):67-80.
Paterson DL. “Collateral damage” from cephalosporin or
quinolone antibiotic therapy. Clin Infect Dis 2004;38(suppl
4):S341-5.

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 21 Genitourinary Infections

Self-Assessment Questions
1. A 21-year-old woman presents to her university medical C. Administer ceftriaxone 1 g intravenously once, then
clinic with concerns of painful urination and increased initiate ciprofloxacin 500 mg orally twice daily for 7
urinary frequency. She has no significant medical his- days.
tory, and her vital signs include temperature 98.4°F, blood D. Initiate levofloxacin 750 mg orally daily for 5 days.
pressure 110/72 mm Hg, heart rate 64 beats/minute,
4. A 45-year-old woman (height 64 inches, weight 72 kg)
and respiratory rate 12 breaths/minute. A urine dipstick
with no known drug allergies is undergoing evaluation
test is positive for both leukocyte esterase and nitrites.
for pyelonephritis, and it is determined that she does not
Which one of the following organisms most likely caused
require hospitalization. No local antibiogram is available,
this patient’s UTI?
and ceftriaxone is currently on a national manufacturer
A. K. pneumoniae backorder. Which one of the following is best to recom-
B. Pseudomonas aeruginosa mend for this patient?
C. S. aureus
A. Ciprofloxacin 400 mg intravenously once
D. Enterococcus faecalis
B. Gentamicin 150 mg intravenously once
2. A 36-year-old woman with a medical history of prediabe- C. Levofloxacin 500 mg intravenously once
tes is undergoing evaluation with a urinalysis to test for D. Tobramycin 450 mg intravenously once
the presence of glucose. Although the glucose test was
5. A 71-year-old man has a medical history significant for
negative, the patient had WBCs, leukocyte esterase, and
hypertension, dyslipidemia, and type 2 diabetes. Over
bacteria in her urine. The patient denies any signs and
the past year, he has had three UTIs, all caused by E. coli
symptoms of a UTI. A urine culture shows greater than
(resistant to ampicillin but susceptible to all other tested
100,000 CFU/mL of P. mirabilis after 48 hours. Which one
antibiotics). He also has concerns about difficulty urinat-
of the following is best to recommend for this patient?
ing and has had low back pain for several months. He
A. Prescribe an antimicrobial according to the is ultimately diagnosed with chronic prostatitis. Which
susceptibility results from the urine culture. one of the following is the best to recommend for this
B. Re-collect the urine sample and counsel the patient patient?
on how to obtain a clean-catch specimen.
A. Ciprofloxacin 500 mg orally every 12 hours for
C. Do not prescribe antimicrobials or obtain further
4 weeks
laboratory testing.
B. Amoxicillin/clavulanate 500 mg/125 mg orally every
D. Initiate nitrofurantoin 100 mg orally twice daily for 5
8 hours for 12 weeks
days.
C. Levofloxacin 750 mg orally once daily for 8 weeks
3. A 27-year-old woman presents to the acute care clinic D. Trimethoprim/sulfamethoxazole 1 double-strength
for evaluation. She has had painful urination and noc- tablet orally every 12 hours for 3 weeks
turia for the past 3 days; however, she has not sought
6. A 23-year-old man has been experiencing intermittent
treatment because she thought it would get better on its
burning on urination for a few weeks and presents to
own. Now, she “feels hot,” and her lower back has begun
his PCP for evaluation. He has no contributory medical
to hurt. A clean-catch urinalysis shows the presence
history. A urine dipstick test is positive for both leuko-
of bacteria and is positive for WBCs and nitrites. The
cyte esterase and nitrites. His vital signs are all within
patient’s vital signs include temperature 102.1°F, blood
normal limits. Local resistance rates of uropathogens to
pressure 136/84 mm Hg, heart rate 82 beats/minute,
trimethoprim/sulfamethoxazole are around 15%. Which
and respiratory rate 14 breaths/minute. She is diag-
one of the following is the best to recommend for this
nosed with pyelonephritis and able to drink some fluids
patient?
in the clinic room. She has a medical history of asthma
in childhood and has no known drug allergies. Uropatho- A. Obtain a urine culture; initiate trimethoprim/
gen resistance in the area to the fluoroquinolones is 7%. sulfamethoxazole 1 double-strength tablet orally
Which one of the following is best to recommend for this twice daily for 7 days; refer to urology for further
patient? evaluation.
B. Initiate ciprofloxacin 500 mg orally twice daily for
A. Admit to the hospital for further treatment.
7 days; no further tests are needed.
B. Initiate nitrofurantoin 100 mg orally twice daily for 5
C. Obtain a urine culture; initiate cefdinir 300 mg orally
days.
twice daily for 10 days.

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 22 Genitourinary Infections

 D. Initiate moxifloxacin 400 mg orally once daily for 7 prophylaxis against UTIs. Which one of the following
days; no further tests are needed; refer to urology for best assesses this patient’s candidacy for antimicrobial
further evaluation. prophylaxis?
A. She is not currently a candidate for antimicrobial
Questions 7 and 8 pertain to the following case. prophylaxis.
J.G. is a 77-year-old man who resides at a long-term care B. She is a candidate for antimicrobial prophylaxis;
facility. He has a complex medical history with several comor- initiate trimethoprim/sulfamethoxazole 40 mg/200
bidities. He requires a permanent indwelling Foley catheter, mg (½ single-strength tablet) orally once daily.
which is changed on a monthly basis. He has no known drug C. She is a candidate for antimicrobial prophylaxis;
allergies. One week after his last catheter change, routine initiate nitrofurantoin 100 mg orally once daily.
quarterly laboratory tests were obtained which include a D. She is a candidate for antimicrobial prophylaxis;
comprehensive metabolic panel, CBC, and urinalysis. The initiate cephalexin 250 mg orally once daily.
urinalysis shows the presence of leukocyte esterase but is
10. A 31-year-old woman is experiencing recurrent UTIs after
negative for nitrites. The patient has no symptoms of a UTI
sexual intercourse. After discussion with her PCP, she
and is at his normal baseline mental status.
has agreed to try postcoital prophylaxis with nitrofu-
7. Which one of the following is best to recommend for rantoin 100 mg. She presents to the pharmacy to obtain
J.G.? the prescription and asks to be counseled on use of the
A. Replace the catheter now and initiate empiric medication. Which one of the following is the best edu-
antimicrobials. cational point regarding prophylaxis to share with this
B. Do not replace the catheter now but initiate empiric patient?
antimicrobials. A. Take 1 capsule immediately before and immediately
C. Replace the catheter now but do not initiate empiric after intercourse.
antimicrobials. B. Take 1 capsule immediately after intercourse.
D. Do not replace the catheter and do not initiate C. Take 1 capsule every evening.
empiric antimicrobials. D. Take 1 capsule three times weekly.
8. Two weeks later, J.G. experiences a temperature of 11. A 51-year-old man presents to the acute care clinic with
101.1°F and has altered mental status from his baseline. concerns of self-reported fever, chills, rectal pain, and
Which one of the following is the best to recommend for dysuria for the past 24 hours. He has never had these
J.G.? symptoms before. Acute prostatitis is diagnosed, and
A. Replace the catheter now and obtain a urinalysis a urine culture returns with the following result: greater
and urine culture from the new catheter; initiate a than 100,000 CFUs of K. pneumoniae.
broad-spectrum antimicrobial according to the local
Minimum
antibiogram until the urine culture returns.
Inhibitory
B. Do not obtain new laboratory tests because they Concentration
were obtained 2 weeks ago and do not replace the Drug (mg/L) Interpretation

catheter; initiate a broad-spectrum antimicrobial Ampicillin ≥8 R

according to the local antibiogram until the urine
Ampicillin/sulbactam <2 S
culture returns.
C. Replace the catheter now and obtain a urinalysis Cefazolin 16 R
and urine culture from the new catheter; initiate Cefepime ≤1 S
an antimicrobial only if the urine culture returns
Ceftriaxone ≤1 S
positive for a pathogenic organism.
D. Obtain a urinalysis and urine culture from the Ciprofloxacin >4 R
catheter already in place; initiate a broad-spectrum Gentamicin ≤2 S
antimicrobial according to the local antibiogram
Imipenem ≤2 S
until the urine culture returns.
Nitrofurantoin ≤ 16 S
9. A 26-year-old woman has had four UTIs over 8 months.
No cultures were obtained for the first two infections, but Piperacillin/
≤4 S
the most recent infections grew E. coli resistant to ampi- tazobactam
cillin, trimethoprim/sulfamethoxazole, and cefazolin. She Trimethoprim/
≤2 S
presents to her PCP today for a routine yearly examina- sulfamethoxazole
tion but wants to discuss the possibility of antimicrobial

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 23 Genitourinary Infections

 Given the culture results, which one of the following is Which one of the following is the best to recommend for
best to recommend for this patient? this patient?
A. Amoxicillin/clavulanate for 4 weeks A. Admit to the hospital and begin treatment with
B. Levofloxacin for 4 weeks ceftriaxone 1 g intravenously once daily.
C. Trimethoprim/sulfamethoxazole for 4 weeks B. Administer trimethoprim/sulfamethoxazole
D. Cephalexin for 4 weeks 80/400 mg orally every 12 hours for 14 days in the
outpatient setting.
12. A 22-year-old otherwise healthy woman presents to the
C. Administer fosfomycin 3 g orally every 24 hours for
outpatient pharmacy with a prescription for trimetho-
three doses in the outpatient setting.
prim/sulfamethoxazole, 1 double-strength tablet orally
D. Administer ceftriaxone 1 g intravenously once, then
twice daily for 7 days for AC. The pharmacist filling the
initiate ciprofloxacin 500 mg orally every 12 hours
prescription knows that E. coli resistance to trimetho-
for 7 days.
prim/sulfamethoxazole in the area is around 28%. Which
one of the following is the most appropriate action for 14. A 45-year-old woman presents to the pharmacy to ask
the pharmacist to take for this patient? about using cranberry products to prevent recurrent
UTIs. Which one of the following is the best educational
A. Call the prescriber for a new prescription for
point to share with this patient?
ciprofloxacin.
B. Call the prescriber to get the length of therapy A. Cranberry products should not be used because
reduced to 3 days. they have not been shown efficacious for preventing
C. Fill the prescription as written and counsel the UTIs.
patient on possible adverse drug events. B. Only cranberry juice has been shown efficacious in
D. Call the prescriber to change the antibiotic to preventing UTI recurrences.
nitrofurantoin 100 mg orally every 12 hours for 5 days. C. Some studies have shown cranberry products
to be efficacious, but evidence is insufficient to
13. A 69-year-old woman presents to an urgent care facil-
recommend one specific formulation over another.
ity with concerns of dysuria, frequency of urination, and
D. Cranberry products can contribute to the
urgency to urinate over the past 3 days. She also reports
development of antimicrobial resistance and should
some left flank pain, which she rates as 4/10 and says it
not be recommended for use.
has not affected her activities of daily living. She denies
nausea, vomiting, and diarrhea. Her vital signs include 15. A 53-year-old man presents to his PCP for burning and
temperature 101.2°F, blood pressure 114/68 mm Hg, heart painful urination for the past 24 hours. He currently has
rate 72 beats/minute, and respiratory rate 14 breaths/min- no other concerns. His vital signs include temperature
ute. Her medical history is significant for hypertension, 98.2°F, blood pressure 120/74 mm Hg, heart rate 68
gastroesophageal reflux disease, and type 2 diabetes. She beats/minute, and respiratory rate 12 breaths/minute. A
has no known drug allergies. Local resistance patterns urine dipstick test is positive for leukocyte esterase and
from the community are unknown. A urine culture is pend- nitrites, and his PCP diagnoses a UTI. Which one of the
ing, and the results from her urinalysis are as follows: following best classifies this patient’s UTI?

Reference A. Lower UTI, uncomplicated

Range Result B. Upper UTI, complicated
Appearance Clear Hazy C. Lower UTI, complicated
D. Upper UTI, uncomplicated
Bacteria None Many

Color Clear Amber

Leukocyte esterase None 3+

Nitrites Negative Positive

Specific gravity 1.002–1.030 1.016

Urine bilirubin None None

Urine glucose None None

Urine pH 5.0–7.0 5.2

Urine protein None None

Urine WBC None 30 cells/high-

power field

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 24 Genitourinary Infections

Learner Chapter Evaluation: Genitourinary Infections

As you take the posttest for this chapter, also evaluate the 8. The teaching and learning methods used in the chapter
material’s quality and usefulness, as well as the achievement were effective.
of learning objectives. Rate each item using this 5-point scale: 9. The active learning methods used in the chapter were
effective.
• Strongly agree
10. The learning assessment activities used in the chapter
• Agree
were effective.
• Neutral
• Disagree 11. The chapter was effective overall.
• Strongly disagree 12. The activity met the stated learning objectives.
13. If any objectives were not met, please list them here.
1. The content of the chapter met my educational needs.
2. The content of the chapter satisfied my expectations.
3. The author presented the chapter content effectively.
OTHER COMMENTS
4. The content of the chapter was relevant to my practice 14. Please provide any specific comments related to any
and presented at the appropriate depth and scope. perceptions of bias, promotion, or advertisement of
commercial products.
5. The content of the chapter was objective and balanced.
15. Please expand on any of your above responses, and/or
6. The content of the chapter is free of bias, promotion, and
provide any additional comments regarding this chapter:
advertisement of commercial products.
7. The content of the chapter was useful to me.

ACSAP 2022 Book 2 • Infectious Diseases in Ambulatory Care 25 Genitourinary Infections