/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/infection-and-isolation/,

/clinical/cckm-tools/content/cpg/infection-and-isolation/name-97539-en.cckm

20170246

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Infection and Isolation

Diagnosis and Treatment of Infections of the Urinary Tract – Adult – Inpatient/Ambulatory

Diagnosis and Treatment of Infections of the Urinary Tract – Adult – Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Infection and Isolation


1
Diagnosis and Treatment of Infections of the Urinary Tract in Adult
Patients – Adult – Inpatient/Ambulatory Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ................................................................................................................................... 3
SCOPE .............................................................................................................................................................. 6
METHODOLOGY .............................................................................................................................................. 6
DEFINITIONS .................................................................................................................................................... 7
INTRODUCTION ............................................................................................................................................... 7
RECOMMENDATIONS ..................................................................................................................................... 7
FIGURE 1. DIAGNOSIS OF UTI IN THE 18-65 YEAR OLD, NON-CATHETERIZED PATIENT ..................... 20
FIGURE 2. DIAGNOSIS OF UTI IN THE ELDERLY AND/OR INSTITUTIONALIZED CATHETERIZED AND
NON-CATHETERIZED PATIENT .................................................................................................................... 21
FIGURE 3. URINARY TRACT INFECTION MANAGEMENT IN ABDOMINAL SOLID ORGAN TRANSPLANT
PATIENTS ....................................................................................................................................................... 23
TABLE 1. AGENTS FOR THE TREATMENT OF UNCOMPLICATED UTI/CYSTITIS .................................... 24
TABLE 2. AGENTS FOR THE TREATMENT OF COMPLICATED UTI/CYSTITIS ......................................... 25
TABLE 3. AGENTS FOR THE TREATMENT OF ACUTE PYELONEPHRITIS – OUTPATIENT .................... 25
TABLE 4. AGENTS FOR THE TREATMENT OF ACUTE PYELONEPHRITIS – INPATIENT ........................ 26
TABLE 5. TREATMENT OF SPECIFIC ORGANISMS .................................................................................... 27
TABLE 6. PREVENTION STRATEGIES ......................................................................................................... 28
TABLE 7. CANDIDATES FOR SCREENING URINALYSIS ........................................................................... 28
UWHEALTH IMPLEMENTATION ................................................................................................................... 29
REFERENCES ................................................................................................................................................ 29
APPENDIX 1. DIAGNOSIS OF URINARY TRACT INFECTION – TOP TEN MYTHS .................................... 35
CPG Contact for Changes:
Philip Trapskin, PharmD, BCPS, Drug Policy Manager
608-263-1328
ptrapskin@uwhealth.org
CPG Contact for Content:
Lucas Schulz, PharmD, BCPS
608-890-8617
lschulz2@uwhealth.org
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

2

Guideline Author(s):
Lucas Schulz, PharmD, BCPS
Barry Fox, MD
Robert Hoffman, MD

Coordinating Team Members:
Joshua Vanderloo, PharmD, Drug Policy Program

Review Individuals/Bodies:
Barry Fox, MD, Alex Lepak, MD Robert Hoffman, MD, Alex Lepak, MD Nasia Safdar, MD,
Jeffrey Pothof, MD, Alexander Young, MD, Kurt Reed, MD, Sarah McAchran, MD, Jennifer
Bellehumeur, Tova Ablove, MD, Marisa Roembke, David Sommerfeld, MD, Gary Bidwell, Tyler
Liebenstein, PharmD

Committee Approvals/Dates:
AMUS: September 2015
P&T Committee: October 2015 (major revisions); March 2013 (initial)/October 2013(minor
revisions)/February 2015 (minor revisions)/November 2016 (minor revisions)

Release Date: November 2016

Next Review Date: October 2018


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

3
Executive Summary
Guideline Overview
This clinical practice guideline is designed to lead prescribers through the evaluation, diagnosis, and treatment of
infections of the urinary tract (UTI). It will focus on difficult diagnostic and treatment scenarios and is intended for use
throughout the continuum of care, including outpatient clinics, emergency department, and inpatient wards.

Key Revisions (Interim Update November 2016)
1. Additional comments to fluoroquinolones to limit use based on emerging FDA warnings and empiric therapies
reordered.
2. Cefpodoxime replaced by cephalexin as empiric therapy given good UWHC susceptibility data.
3. Updated nitrofurantoin guidance to indicate that nitrofurantoin may be given to patients with CRCL as low as 30
mL/min with close monitoring for resolution of infection.

Key Practice Recommendations
1. In general, urinalysis is a poor predictor of UTI and it is probably indicated to be combined with clinical manifestations
before the diagnosis of UTI is made or antimicrobial therapy initiated. (Class IIa, Level C)
1.1. Urine color/clarity or odor should not be used alone to diagnosis or start antimicrobial therapy in any patient
population. (Class III, Level B)
1.2. Urine leukocyte esterase should not be used alone to diagnosis or to initiate antimicrobial therapy in any patient
population. (Class III, Level B)
1.3. Urine nitrates should not be used alone to diagnosis or to initiate antimicrobial therapy in any patient population.
(Class III, Level B)
1.4. The presence of bacteria in the urine on microscopic examination without UTI symptoms is NOT recommended
for the diagnosis of UTI. (Class III, Level B)
2. Pyuria accompanying asymptomatic bacteriuria is NOT an indication for antimicrobial treatment in the general
population.1 (Class III, Level A).
2.1. The choice to treat with antimicrobials should only be made after evaluation of the entire clinical picture,
consideration for the reasons for pyuria, and identification as the urine as most likely source of infection (see
Diagnosis section for recommendations for work up of difficult patients).
3. Diagnosis based on results of culture of urine specimen collected in a manner that minimizes contamination is
reasonable. (Class IIa, Level A)1
3.1. The clean-catch method is preferred for collection as it minimizes infection risk inherent in catheterization2-5
(Class IIa, Level B), but specimens with more than five epithelial cells should be considered unreliable and are
probably indicated for recollection by clean-catch or straight catheterization.
4. In all elderly patients, acute mental status change and functional decline are nonspecific clinical
manifestations of several circumstances, including, but not limited to dehydration, hypoxia, or medication
(including polypharmacy) adverse reactions. It is reasonable to correlate UTI diagnosis with other signs of systemic
inflammation, including leukocytosis.6 (Class IIb, Level B)
4.1. It is may be reasonable to conclude UTI diagnosis in catheterized patients as a diagnosis of exclusion in the
absence of localized urinary tract findings.6 (Class IIb, Level C)
4.2. In patients with a clinically suspected UTI, a change in urine character (color or odor) does not add to the
diagnostic value. Therefore, urine color and odor should not be used alone to diagnose or start antimicrobial
therapy (Class III, Level B).7 However, these two symptoms are also frequently demonstrated in patients with
asymptomatic bacteriuria.8,9
4.3. Falls without localizing urinary symptoms were not associated with bacteriuria or pyuria.8,9
4.4. Elderly patients, especially those with dementia or indwelling Foley catheters, have high rates of bacteriuria and
may not have UTI symptoms10. Diagnosis of sepsis of a urinary source is NOT recommended in the absence of
urinary symptoms because of bacteriuria. (Class III, Level C)
5. Nitrofurantoin 100 mg PO BID for five days is recommended as first line therapy for treatment of uncomplicated
cystitis.
11
(Class I, Level A)
5.1. More than 95% of E.coli isolates UWHC as sensitive to nitrofurantoin (UWHC Antibiogram).
5.2. Patients with Stage IV or V kidney disease (CrCL <30 mL/min) should not receive nitrofurantoin.12 (Class III,
Level A)
5.3. Patients with Stage III kidney disease (CrCL 31-59 mL/min), nitrofurantoin may be considered, but patients
should be monitored closely for resolution of infection.13,14 (Class IIa, Level A)

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

4
Treatment of specific organisms
Organism Treatment Option Notes
Mixed genitourinary flora in non-
catheterized patient
Recollection Generally represent poor specimen collection. Suggest
recollection.
Mixed genitourinary flora in
catheterized patient
Target predominate
organism
If no predominating organism, likely colonization.
With predominating organism, tailor treatment to said organism.
Staphylococcus saprophyticus
Amoxicillin/clavulanate
500/125 mg PO BID x 7
days OR
Amoxicillin 500 mg PO
TID x 7-10 daysA
Second leading cause of UTI in young women.

Alternative regimens include ciprofloxacin 250 mg PO BID x 3-7
days, trimethoprim/sulfamethoxazole 160/800 mg PO BID x7
days, or cephalexin 250 mg PO BID x 7-10 days.A
Coagulase-negative
Staphylococcus
(non-saprophyticus)
Vancomycin IVB
Goal trough 10-15
Rarely pathogens in the urinary tract and generally represent poor
specimen collection, unless from indwelling catheter.
Staphylococcus aureus Tailored to antimicrobial
susceptibilities
Rarely causes ascending infection de novo. Patients should have
blood cultures drawn and hematogenous route investigated.
Enterococcus spp.
(ampicillin-susceptible)
Amoxicillin 500 mg PO
BID x 3-7 daysA
Susceptibility testing should guide final therapy. Ampicillin
susceptibility predicts piperacillin activity.

Alternative regimen of vancomycin for patients with true penicillin
or β-lactam allergy.
Enterococcus spp.
(vancomycin-resistant)
Often asymptomatic and
no treatment required.
Tailor to antimicrobial
susceptibilities.

Duration of therapy:
Remove catheter: 1-3
days
Without catheter: 7-14
days
Frequent colonizer or cause of asymptomatic bacteriuria. Once GI
colonization, eradication Is not possible and hence it may
frequently appear in the urinary system.

Alternative regimens (in preferential order) include nitrofurantoin,
fosfomycin, doxycycline, tetracycline, daptomycin 4mg/kg,
linezolid PO, or tigecycline.
Proteus spp. Tailor to antimicrobial
susceptibilities x 14 days
High propensity to produce renal calculi. Relapsing Proteus
infections should prompt an evaluation for urinary calculi.
Anaerobic organisms Empiric treatment NOT
recommended
Rarely pathogens in the urinary tract and the microbiology lab will
not routinely perform cultures.
Gardnerella vaginalis Recollection May be isolated from urine but rarely pathogenic. Investigate
sample quality to assess pathogenicity.
Ureaplasma urealyticum Recollection/special
collection
May be isolated from urine but rarely pathogenic. Investigate
sample quality to assess pathogenicity.
Mycoplasma hominis Recollection/special
collection
May be isolated from urine but rarely pathogenic. Investigate
sample quality to assess pathogenicity.
Candida albicans Fluconazole 100-400 mg PO daily x14 daysA Remove or replace catheter if appropriate.
Candida glabrata
Low risk Remove or replace catheter if appropriate.
Candida glabrata
High risk (includes severely
immunocompromised and
febrile; renal transplant; patients
with retained genitourinary
hardware; and patients
undergoing genitourinary
procedure)
Remove or replace
catheter.

Treatment with
fluconazole 400-800 mg
IV/PO dailyA
Most common organism in UW renal transplant patients; however,
most were asymptomatic.

Imaging of the kidneys and collection system should be
performed

Non-fluconazole antifungals and echinocandins should not be
used for treatment.

Bladder irrigation with amphotericin B 50 mg daily x 7-10 days.
Corynebacterium urealyticum Vancomycin IV
B

Goal trough 10-15
Common in renal transplant population, otherwise investigate
sample quality to assess pathogenicity.

Consider urology consultation as this organism may cause
encrusting pyelitis.
A



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

5

Companion Documents
ξ Renal Function-based Dose Adjustments – Adult – Inpatient Clinical Practice Guideline
ξ Catheter-Associated Urinary Tract Infection (CAUTI) – Adult – Inpatient Clinical Practice Guideline
ξ Antibiotics for the Treatment of Gram-negative Infections – Adult – Inpatient Clinical Practice Guideline
ξ UWHC Antibiogram
ξ Treatment of Patients with Reported Allergies to Beta-Lactam Antibiotics – Adult – Inpatient Clinical Practice
Guideline
ξ Intravenous Vancomycin Use – Adult – Clinical Practice Guideline
ξ Preventative Health Care – Pediatric/Adult - Ambulatory

Pertinent UWHC Policies & Procedures
ξ Indwelling Urinary Catheter Removal – Inpatient – Adult Protocol [25]
ξ Bladder Management – Pediatric – Inpatient [8]
ξ Bladder Management – Inpatient – Adult Protocol [26]
ξ Acute Spinal Cord Injury Bladder Management – Adult – Inpatient [144]
ξ UWHC Policy 3.14AP: Sterile Intermittent Catheterization Program
ξ UWHC Policy 3.15AP: Sterile Intermittent Straight Catheterization for Bladder Decompression and/or Specimen
Collection (Adult and Pediatric)
ξ UWHC Policy 3.18A: Replacement and Care of a Suprapubic Catheter
ξ UWHC Policy 3.28: Collecting a Urine Specimen from an Indwelling Urinary Catheter
ξ UWHC Policy 3.30: Continuous Bladder Irrigation (CBI) (Adult)
ξ UWHC Policy 3.31: Insertion, Removal and Maintenance of an Indwelling Urinary Catheter (IUC) (Adult and
Pediatric)
ξ UWHC Policy 13.12: Basic Care Standards (Adult)

Patient Resources
ξ Health Facts for You #4286: Urinary Tract Infections: Information for Women
ξ Health Facts for You #5914: Urodynamic Testing
ξ Health Facts for You #7355: Urinary Catheters and Urinary Tract Infections
ξ Health Facts for You #7833: Urinary Catheters and Urinary Tract Infections (Spanish)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

6

Scope
Disease/Condition
This clinical practice guideline is designed to lead prescribers through the evaluation, diagnosis, and treatment of
infections of the urinary tract (UTI).

Clinical Specialty
All medical specialties

Intended Users
Physicians, Advanced Practice Providers, Nurses, and Pharmacists

Objective
To decrease number of urine cultures ordered per 1000 patient days.
To optimize antibiotic utilization for treatment of UTI.

Target Population
Patients with signs and symptoms of urinary tract infection cared for in outpatient clinics, the emergency department, and
inpatient wards.

Interventions and Practices Considered
Diagnosis of urinary tract infections, treatment of urinary tract infections with antimicrobials, and avoidance of
antimicrobial use in patients without urinary tract infection following evaluation.

Major Outcomes Considered
1. Successful treatment of urinary tract infections measured by successful infection resolution
2. Avoidance of antimicrobial use in patients without urinary tract infection

Methodology
Electronic database searches (i.e., PUBMED) were conducted and workgroup members to collect evidence for review.
Expert opinion, clinical experience, and regard for patient safety/experience were also considered during discussions of
the evidence. A modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) developed
by the American Heart Association and American College of Cardiology was used to assess the Quality and Strength of
the Evidence in this Clinical Practice Guideline.15

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

7
Definitions (modified from Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases 7th ed.)
1. Significant Bacteriuria
1.1. Greater than or equal to 105 bacteria per mL of voided urine
1.1.1. In healthy women with acute cystitis , lower colony counts may represent significant bacteriuria
1.2. Greater than or equal to 103 bacteria per mL of catheterized urine or symptomatic female
2. Asymptomatic bacteriuria – significant bacteriuria in patients without symptoms
3. Cystitis – syndrome involving dysuria, frequency, urgency, and occasionally suprapubic tenderness
3.1. These symptoms may also be caused by urethritis (e.g. gonorrhea or Chlamydia) or non-infectious causes
4. Acute pyelonephritis – syndrome often involving flank pain, tenderness, and fever often associated with cystitis
symptoms. Flank pain is not required for this diagnostic consideration.
4.1. These symptoms may also be caused by non-infectious etiologies (e.g. renal infarction or calculus)
5. Uncomplicated UTI – infection in a structurally and neurologically NORMAL urinary tract
6. Complicated UTI – infection in a urinary tract with functional or structural abnormalities, including indwelling catheters
and calculi
6.1. Includes infections in men, pregnant women, children, and other patients who are hospitalized or in the health-
care setting for extended periods of time
7. Relapse – recurrence of bacteriuria with the same infecting organism(s) caused by persistence of the organism(s) in
the urinary tract
8. Reinfection – recurrence of bacteriuria with a different infecting organism than the original infecting bacterium. This
may also be the same organism if it persisted in the vagina or feces.
9. Sepsis of a urinary source – Sepsis syndrome caused by UTI
10. Chronic UTI – persistence of the same organism for months or years with clinical relapses after treatment.
11. Chronic bacteriuria – persistence of one or more bacteria colonizing the urinary tract in the absence of clinical
symptoms
12. Recurrent UTI – recurrence of episodes of uncomplicated or complicated UTI with the same or different organism
beyond the expected frequency
13. TMP-SMX – Trimethoprim-sulfamethoxazole
14. GU – Genitourinary

Introduction
Infections of the urinary tract are one of the most common sites for bacterial infection and are the most common type of
infection in the United States, utilizing $1.6 billion dollars in 2002.16 The accurate diagnosis and treatment of urinary tract
infections plays an important role in cost-effective medical care and appropriate antimicrobial utilization. Some patients
receive antibiotic therapy when treatment is not indicated. The prevalence of bacteriuria in young non-pregnant women is
1-5%.17,18 As patients age, the rate of asymptomatic bacteriuria increases.10 The rate of bacteriuria in men is much lower,
fewer than 0.1%.19 The presence of bacteria in the urine is not necessarily an indication for antimicrobial therapy.
Indications for treatment are discussed in the guideline below. Preventative care and prophylactic agents may reduce the
risk of UTI and are discussed in the guideline as well. However, manipulation of the urinary tract via instrumentation of
urinary tract increases the risk of developing UTI. One catheterization of the bladder results in UTI in 1% of ambulatory
patients20 and indwelling catheters with open drainage systems results in a UTI in nearly 100% of patients in three to four
days.21,22

The incidence of asymptomatic bacteriuria increases with age (10% of males and > 20% of females older than 65
years)1,10,23-27 and the overuse of antibiotics leads to antibiotic resistance and adverse effects, including risk of C.
difficile infection.28-32 The choice to treat with antimicrobials should only be made after evaluation of the entire clinical
picture and identification as the urine as most likely source of infection.

Recommendations

Diagnosis (see Appendix 1)
1. Signs and symptoms – General principles
1.1. In patients with dysuria, frequent or urgent urination, suprapubic pain or tenderness a diagnosis of urinary tract
infection,33,34 sexually transmitted infection, or noninfectious cystitis should be strongly considered. 20,21 (Class I,
Level A)
1.1.1. Other diagnoses may need to be considered based on clinical presentation. (Class IIb, Level C)
1.2. Vaginal symptoms (e.g. vaginitis, urethritis) should prompt alternative diagnoses.33,34 (Class I, Level A) Queries
must be made for these symptoms to avoid misdiagnosis.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

8
1.3. Diagnosis based on results of culture of urine specimen collected in a manner that minimizes contamination is
reasonable. (Class IIa, Level A)1
1.3.1. The clean-catch method is preferred for collection as it minimizes infection risk inherent in
catheterization2-5 (Class IIa, Level B), but specimens with more than five epithelial cells should be
considered unreliable and are probably indicated for recollection by clean-catch or straight
catheterization.
1.4. Asymptomatic women: bacteriuria is defined as two consecutive voided urine specimens with isolation of the
same bacterial strain with quantitative counts ≥105 CFU/mL1
1.5. Men: a single clean-catch voided urine specimen with one bacterial species isolated with quantitative count
≥105 CFU/mL.1
1.6. Catheterized men or women: a single urine specimen with one bacterial species isolated with quantitative count
≥102 CFU/mL may be considered significant (since the natural history is for colony counts to increase to 105
CFU/mL in 48 to 72 hours).35
1.7. Paraplegic patients may only present with fever or hypothermia, increased spasticity, and/or autonomic
dysreflexia.36 Consideration of UTI diagnosis is reasonable with these signs and symptoms. (Class IIb, Level B)

2. Clinical laboratory findings for the diagnosis of bacteriuria (not UTI) and decision to start antimicrobial
therapy
2.1. In general, urinalysis is a poor predictor of UTI and it is probably indicated to be combined with clinical
manifestations before the diagnosis of UTI is made or antimicrobial therapy initiated. (Class IIa, Level C)
2.2. Urine color/clarity or odor should not be used alone to diagnosis or start antimicrobial therapy in any patient
population. (Class III, Level B)
2.2.1. Visual inspection of urine clarity is not helpful in diagnosing UTI in women. This is not recommended.37
(Class III, Level B)
2.2.2. In patients with a clinically suspected UTI, a change in urine character (color or odor) does not add to
diagnostic value. Therefore, urine color and odor should not be used alone to diagnose or start
antimicrobial therapy (Class III, Level B).7
2.2.3. Foul smelling and/or cloudy urine is not a reliable indicator of infection in catheterized patients and
should NOT be an indication alone for testing the urine or starting antimicrobial therapy.38 (Class III,
Level A)
2.3. Urine leukocyte esterase should not be used alone to diagnosis or to initiate antimicrobial therapy in any patient
population. (Class III, Level B)
2.3.1. A dipstick leukocyte esterase test has high sensitivity and specificity (80-90% and 95-98%,
respectively); however, a positive leukocyte esterase alone is NOT recommended for diagnosis of
UTI.39,40 (Class III, Level B)
2.3.2. A negative leukocyte esterase in the presence of UTI symptoms may still prompt a urine culture if
clinically suspected39,40 (Class IIa, Level B), but also prompt a search for urethritis, vaginitis, or sexually
transmitted infection.
2.3.3. A negative leukocyte esterase AND a negative urine nitrate probably rules out infection in pregnant
women, elderly patients, family medicine patients, and urology patients.41 Alternative diagnosis
investigation are probably indicated in this scenario (Class IIb, Level B)
2.4. Urine nitrates should not be used alone to diagnosis or to initiate antimicrobial therapy in any patient population.
(Class III, Level B)
2.4.1. Urine nitrate has low false-positive rate. Diagnosis of UTI can be indicated in a patient with elevated
urine nitrate.39,42 (Level IIa, Level B)
2.4.2. A negative leukocyte esterase AND a negative urine nitrate probably rules out infection in pregnant
women, elderly patients, family medicine patients, and urology patients.41 Alternative diagnosis
investigation are probably indicated in this scenario (Class IIb, Level B)
2.5. Quantitative urine WBC should not be used alone to diagnosis or to initiate antimicrobial therapy in any patient
population. (Class III, Level B)
2.5.1. In neutropenic or leukopenic patients, the WBC count may be low and reflex culture may not occur. The
Microbiology Lab should be contacted and an order for urine culture ordered if urinary symptoms are
present and urinary source of infection is suspected. (Class IIb, Level C)
2.5.2. Patients with oliguria or anuria (including dialysis) usually have some degree of pyuria.
2.6. Urine Bacteria
2.6.1. The presence of bacteria in the urine on microscopic examination without UTI symptoms is NOT
recommended for the diagnosis of UTI.42 (Class III, Level B)
2.6.2. In patients without an indwelling catheter the following cutoffs should define clinically significant
bacteriuria6:
ξ ≥ 105 CFU/mL of ≤ 2 species of microorganisms in voided culture
ξ ≥ 102 CFU/mL of any number of microorganisms in a straight cath culture
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

9
2.6.3. In patients with an indwelling catheter, ≥103 CFU/mL of any organism(s) defines clinical significant
bacteriuria since this is predictive of higher numbers within 48 hours.6
2.7. Urine squamous epithelial cells
2.7.1. A good urine specimen has fewer than five epithelial cells per low power field on UA. Recollection or
straight catheterization may be considered for poor specimens. (Class IIb, Level C)
2.8. Indications for urine culture in patients with a urinary catheter in place include6,43-47 (Class I, Level C):
ξ new fever or rigors with negative clinical assessment for other more likely etiologies
ξ acute alteration of mental status with negative clinical assessment for other more likely etiologies
ξ suprapubic pain or tenderness
ξ acute gross hematuria
ξ costovertebral pain or tenderness to palpation
ξ increased spasticity or autonomic dysreflexia in patients with altered neurologic sensation
ξ alteration in medical condition (e.g. unexplained increase or decrease in WBC count) with negative clinical
assessment for other more likely etiologies of a patient for whom fever may not be a reliable sign
2.9. Indications for urine culture in non-catheterized patients with pyuria or hematuria (without squamous epithelial
cells on urinalysis) include (Class I, Level C):
ξ suspected pyelonephritis with classic signs and symptoms48
ξ symptoms of cystitis or prostatitis in the absence of STI48
ξ new fever or rigors after other more likely etiologies have been excluded
ξ acute alteration of mental status after other more likely etiologies have been excluded
ξ alteration in medical condition (e.g. unexplained increase or decrease in WBC count) of a patient for whom
fever may not be a reliable sign
ξ rarely, as a test of cure when medically indicated
2.10. Inappropriate indications for urine culture include (Class I, Level C):
ξ abnormal urine quality (e.g. color, odor, turbidity)37,38,44
ξ routine component of “pan-culture” in fever workup until other etiologies have been excluded
ξ asymptomatic pyuria not meeting above criteria
ξ asymptomatic elderly, diabetic, or institutionalized patient not meeting criteria above
ξ routine documentation of bacteriuria clearance

3. Dealing with altered mental status in the elderly
3.1. In all elderly patients, acute mental status change and functional decline are nonspecific clinical
manifestations of several circumstances, including, but not limited to dehydration, hypoxia, or medication
(including polypharmacy) adverse reactions. It is reasonable to correlate UTI diagnosis with other signs of
systemic inflammation, including leukocytosis.6 (Class IIb, Level B)
3.1.1. It is may be reasonable to conclude UTI diagnosis in catheterized patients as a diagnosis of exclusion
in the absence of localized urinary tract findings.6 (Class IIb, Level C)
3.1.2. In patients with a clinically suspected UTI, a change in urine character (color or odor) does not add to
the diagnostic value. Therefore, urine color and odor should not be used alone to diagnose or start
antimicrobial therapy (Class III, Level B).7 However, these two symptoms are also frequently
demonstrated in patients with asymptomatic bacteriuria.8,9
3.1.3. Falls without localizing urinary symptoms were not associated with bacteriuria or pyuria.8,9
3.2. Signs and symptoms usually associated with UTI are frequently absent in the catheterized patient.45 Foul
smelling and/or cloudy urine is not a reliable indicator of infection and should NOT be an indication
alone for testing the urine or starting antimicrobial therapy.38 (Class III, Level A)
3.3. Elderly patients, especially those with dementia or indwelling Foley catheters, have high rates of bacteriuria and
may not have UTI symptoms10. Diagnosis of sepsis of a urinary source is NOT recommended in the absence of
urinary symptoms because of bacteriuria. (Class III, Level C)
3.4. UTI diagnosis is reasonable when there are localizing genitourinary signs and symptoms and a positive urine
culture result.6,46 (Class IIa , Level B)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

10
3.5. Diagnosis of UTI is reasonable by meeting the following clinical criteria (must meet both Criteria 1 and 2).6,46
(Class IIa, Level B)
No Indwelling Catheter With Indwelling Catheter
Criteria 1 (must have at least one subcriterion)
ξ Acute dysuria or acute pain, swelling, or tenderness
of the testes, epididymis, or prostate
ξ Fever or leukocytosis AND localized urinary tract
criteria (acute CVA pain/tenderness, suprapubic
pain, gross hematuria, new or increased
incontinence, urinary frequency or urgency)
Criteria 1 (must have at least one subcriterion)
ξ Fever, rigors, or new-onset hypotension, with no
alternative site of infection
ξ Acute change in mental status or acute functional
decline, with no alternative diagnosis AND
leukocytosis
ξ New-onset suprapubic pain or CVA pain/tenderness
ξ Purulent discharge from around the catheter or acute
pain, swelling, or tenderness of the testes,
epididymis, or prostate
Criteria 2 (must have at least one subcriterion)
ξ ≥ 105 CFU/mL of ≤ 2 species of microorganisms in
voided culture
ξ ≥ 102 CFU/mL of any number of microorganisms in a
straight cath culture
Criteria 2
ξ Urinary catheter specimen culture with ≥105 CFU/mL
of any organism(s) (Urinary catheter specimens
should be collected following replacement of the
catheter if the current catheter has been in place
longer than14 days)

3.6. A UTI diagnosis is reasonable without localizing symptoms if a blood culture isolate is the same as the organism
isolated from the urine and there is not alternate site of infection.6(Class IIa, Level B)
3.7. In the absence of a clear alternative source of infection, fever or rigors with a positive urine culture result in the
non-catheterized resident, or acute confusion in the catheterized patient will often be treated as UTI. However,
evidence suggests that most of these episodes are likely not due to infection of the urinary tract.6 (Class IIb,
Level B)
3.8. Residents with intermittent or condom catheters are at lower risk for UTI and are probably in the same risk
category as those with no indwelling catheter.46 (Class IIa, Level C)

4. Outpatient Visit – lab confirmation/screening
4.1. In women with symptoms consistent with UTI and without a history of laboratory-confirmed UTI, an office visit
with UA is recommended.33 (Class I, Level B)
4.1.1. Women with frequent UTI recurrences and prior confirmation by diagnostic tests who are aware of their
symptoms may be empirically treated.33,34 (Class I, Level B)
4.2. Because of the small risk of iatrogenic introduction of bacteria into the bladder, urinary catheterization to obtain
a specimen is NOT routinely recommended.20,21 (Class III, Level B) However, with patients for whom the quality
of a clean catch urine sample has or may be compromised (i.e. more than 10 epithelial cells), catheterization
may be considered. (Class IIb, Level C)

5. Special populations
5.1. Pregnancy
5.1.1. Pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy,
and they should be treated if the results are positive, assuming collection quality is adequate,
regardless of symptoms.33 (Class I, Level A)
5.2. Renal Transplant
5.2.1. In patients with a history of renal transplant it is reasonable to screen for bacteriuria by urine culture
with every clinic visit during the early postoperative period for the first three to six months and to treat if
the results are positive based on the renal transplant standard operating procedures. (Class IIa, Level
B)
5.2.2. Candiduria in the renal transplant patient is likely a marker of severity of illness and treatment of
asymptomatic candiduria does not appear to improve outcomes. Removal of the indwelling bladder
catheter, if present, is reasonable.49 (Class IIb, Level B)
5.3. Elderly, community dwelling patients
5.3.1. Screening for bacteriuria in the elderly, community dwelling patients, with or without indwelling catheter
is not recommended.50,51 (Class III, Level B)
5.3.1.1. Elderly patients in the community have a prevalence of asymptomatic bacteriuria of up to
19%50, or higher in older age groups.
5.4. Patients from skilled nursing facilities or institutionalized patients
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

11
5.4.1. Screening for bacteriuria in elderly, institutionalized patients with or without indwelling catheter is not
recommended.50,51 (Class III, Level A)
5.4.1.1. Elderly patients in a long term care facility have a prevalence of asymptomatic bacteriuria of
up to 50%.51
5.5. Up to 23% of patients with a short-term (fewer than two weeks) indwelling catheters have bacteriuria.50 Up to
100% of patients with a long-term (longer than two weeks) indwelling catheters have bacteriuria.52
5.6. Diabetic women
5.6.1. Screening for bacteriuria in diabetic women is NOT recommended.53 (Class III, Level A)
5.6.1.1. Up to 27% of women with diabetes have asymptomatic bacteriuria.53

Asymptomatic Bacteriuria
6. Pyuria accompanying asymptomatic bacteriuria is NOT an indication for antimicrobial treatment in the general
population.1 (Class III, Level A).
6.1. The choice to treat with antimicrobials should only be made after evaluation of the entire clinical picture,
consideration for the reasons for pyuria, and identification as the urine as most likely source of infection (see
Diagnosis section for recommendations for work up of difficult patients).
7. Pregnancy - Pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy,
and they should be treated if the results are positive regardless of symptoms.33 (Class I, Level A)
7.1. Antimicrobial treatment of asymptomatic bacteriuria decreases the risk of pyelonephritis in pregnant women by 9
to 20 fold.54
7.2. Cephalexin is reasonable for treatment of asymptomatic bacteriuria in pregnancy since cephalosporins are
considered among the safest treatments during pregnancy.55 (Class IIa, Level B)
7.3. Treatment with sulfonamides (trimethoprim-sulfamethoxazole (TMP-SMX) Pregnancy Category C) or
nitrofurantoin (Pregnancy Category B) is reasonable at doses listed below given their historical use in pregnant
women without issue. (Class IIa, Level B)
7.3.1. TMP-SMX may interfere with folic acid metabolism. No well-controlled studies exist in pregnant women;
however, a retrospective study of 186 pregnancies showed a reduced incidence of congenital
abnormalities in women receiving TMP-SMX.56 The use of TMP-SMX in pregnant women is cautioned
given theoretical detriments. (Class III, Level B).
7.3.2. Nitrofurantoin use in pregnant women should be avoided when the onset of labor is imminent because
of the possibility of hemolytic anemia due to immature erythrocyte enzyme systems. Use of
nitrofurantoin after 38 weeks is contraindicated.57 (Class III, Level B)
7.4. Fosfomycin (Pregnancy Category B) has been used safely and effectively in the treatment of bacteriuria in
pregnant women58,59 and may be considered for the treatment of resistant organisms. 45,46 (Class IIa, Level B)
7.5. A meta-analysis was unable to determine an optimal duration of anti-infective therapy.60 Therefore, a single-
dose, three-day, four-day, or seven-day treatment regimen may be considered. (Class IIa, Level A)
8. The incidence of asymptomatic bacteriuria increases with age (10% of males and 20% of females older than 65
years)1,10,23-27 and the overuse of antibiotics leads to antibiotic resistance, exposes patients to potential side effects,
and has not been shown to reduce mortality28-31; therefore, treatment for patients without symptoms is NOT
recommended (Class III, Level B)
9. The treatment or prophylaxis of asymptomatic bacteriuria may be considered in patients with an urinary stent.61 (Class
IIb, Level B)
9.1. Urinary stents in place for fewer than 2 weeks have not demonstrated an increased rate of colonization.61
10. Acute kidney injury and chronic renal failure
10.1. In healthy women, E.coli bacteriuria is not associated with a decline in renal function or with the development of
end-stage renal failure.62
10.2. UTI and pyelonephritis are rarely considered on the differential diagnosis of acute kidney injury.63 Patients with
AKI and bacteriuria should be considered for pyelonephritis IF the clinical picture supports infection of the
urinary tract. (Class IIb, Level C)
10.3. Antibiotics should be considered in a patient with clinical signs of UTI and AKI.1,48
10.4. In patients with chronic renal failure, 27% have bacteriuria and 38% have pyuria; however, only 7% had
symptomatic UTI.64 No significant correlation was found between bacteriuria and urine output. Pyuria was
significantly more frequent in oliguric or hemodialysis patients. Therefore, in oliguric patients with chronic renal
failure, asymptomatic bacteriuria is common and the patient should be evaluated for systemic symptoms before
beginning antimicrobial therapy.

Empiric and Definitive Treatment of Uncomplicated Cystitis
11. The therapeutic options below are listed in their preferred order.
12. The optimal therapy depends on many factors and each medication has risks and benefits which must be considered
when choosing treatment
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

12
13. The choices below may be used for the empiric treatment of uncomplicated cystitis. Definitive treatment should be
guided by susceptibility results. (Class IIb, Level C)
13.1. Fosfomycin susceptibility testing is limited based on limited approval by the FDA; however, resistance rates in
E.coli 65 and other multi-drug resistant organisms is low.66

14. Nitrofurantoin
14.1. Nitrofurantoin 100 mg PO BID for five days is recommended as first line therapy for treatment of uncomplicated
cystitis.
11
(Class I, Level A)
14.1.1. More than 95% of E.coli isolates UWHC as sensitive to nitrofurantoin (UWHC Antibiogram).
14.2. Patients with Stage IV or V kidney disease (CrCL <30 mL/min) should not receive nitrofurantoin.12 (Class III,
Level A)
14.3. Patients with Stage III kidney disease (CrCL 31-59 mL/min), nitrofurantoin may be considered, but patients
should be monitored closely for resolution of infection.13,14 (Class IIa, Level B)
14.4. In the case of diagnostic uncertainty with regards to pyelonephritis, nitrofurantoin should not be chosen since
tissue concentrations are minimal.67 (Class III, Level A)

15. Trimethoprim-sulfamethoxazole (TMP-SMX)
15.1. TMP-SMX 160-800 mg PO BID for three days is recommended for the treatment of outpatient uncomplicated
cystitis. (Class I, Level A)
15.1.1. TMP-SMX doses may need to be adjusted for renal function. See Renal Function-based Dose
Adjustments – Adult – Inpatient Clinical Practice Guideline.
15.1.2. Recommendation for use is based on resistance rates of uropathogens at UWHC during the past year.
If the local resistance rate exceeds 20%, use is not recommended. (Class III, Level C)
15.1.3. The current rate of outpatient E.coli urine-isolated resistance is 18% (data provided from UWMF clinics
and EXCLUDES urology and transplant clinics).
15.1.4. The current rate of inpatient, common Gram-negative urine isolates (Enterobacter cloacae, E. coli,
Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa) resistant
to TMP-SMX is 24%.

16. Fluoroquinolones
16.1. Ciprofloxacin 250 mg PO twice daily or levofloxacin 250 mg PO daily for three days is reasonable for the
treatment of uncomplicated cystitis (Class IIb, Level A); however fluoroquinolone-associated collateral damage
as manifested by increased resistance rates is an important issue to consider when choosing fluoroquinolone
treatment over alternatives.68
16.1.1. The current rate of fluoroquinolone resistance in outpatient E.coli urine isolates is 10% (data provided
from UWMF clinics and EXCLUDES urology and transplant clinics).
16.1.2. The current rate of inpatient, common Gram-negative urine isolates (Enterobacter cloacae, E. coli,
Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa) resistant
to fluoroquinolones is 19%.
16.2. Levofloxacin may also be considered for the treatment of concomitant lower respiratory tract infection and
urinary tract infection as an inpatient.
16.3. Ciprofloxacin and levofloxacin doses may need to be adjusted for renal function. See Renal Function-based
Dose Adjustments – Adult – Inpatient Clinical Practice Guideline.
16.4. Moxifloxacin should not be used for UTI treatment because it achieves very low urine levels.69 (Class III, Level
B)

17. β-lactam antibiotics
17.1. Short course (three days) of β-lactam antibiotics are generally less effective than other antimicrobials used for
short course therapy and should not be used as first-line agents for short course therapy unless the patient is
unable to receive alternatives listed above.48 (Class III, Level A).
17.1.1. Cefpodoxime 100 mg PO BID demonstrated equivalent clinical and microbiological outcomes as
trimethoprim/sulfamethoxazole at day four through seven. 70
17.1.1.1. Cephalexin is reasonable as empiric therapy given high susceptibility rates at UW Health.
(Class IIa, Level C)
17.1.2. When the antimicrobial susceptibility of the bacteria is known at treatment initiation, amoxicillin 500mg
PO BID or cephalexin 500mg PO BID for seven days (if susceptible) is as effective as agents listed
above and are reasonable. (Class IIa, Level B)
17.1.3. If a β-lactam agent is chosen, therapy for a full seven-day course is probably recommended.48 (Class
IIa, Level A)
17.2. β-lactam antibiotic doses may need to be adjusted for renal function. See Renal Function-based Dose
Adjustments – Adult – Inpatient Clinical Practice Guideline.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

13

18. Fosfomycin
18.1. Fosfomycin 3 g PO once is recommended for treatment of uncomplicated cystitis.71 (Class I, Level B)
18.2. Fosfomycin 3 g PO every 72 hours for 3 doses is reasonable for treatment of complicated cystitis without
bacteremia.71 (Class IIa, Level B)
18.2.1. Under unusual circumstances, repeat dosing for durations longer than seven days may be considered
for treatment of virulent, multi-drug resistant bacteria. (Class IIa, Level C)
18.3. Fosfomycin has broad spectrum of activity against Gram-negative and Gram-positive organisms including
vancomycin-resistant Enterococcus (VRE) and extended spectrum β-lactamases (ESBL) and is effective for the
treatment such infections in the urinary tract.72
18.4. In the case of diagnostic uncertainty with regards to pyelonephritis or with potential bacteremia, fosfomycin
should generally not be chosen since serum concentrations are minimal.73 (Class III, Level A).

Treatment of Complicated UTI
19. In general, broader spectrum empiric treatment followed by a tailoring of therapy based on culture and susceptibility
results may be reasonable. (Class IIb, Level C)
20. If the patient is moderately ill without a history of resistant uropathogens and without recent fluoroquinolone use,
ciprofloxacin or levofloxacin monotherapy is reasonable74,75 (Class IIa, Level B), although the recent 20% outpatient
resistance rates at UWHC and UWMF suggests this monotherapy strategy may not be appropriate.
20.1. UWHC and UWMF outpatient clinics generally have lower fluoroquinolone resistance rates than inpatient wards
20.2. UWHC Hospital resistance rates may approach 20%.
21. If the patient is severely ill, it is reasonable to select broad-spectrum Gram-negative coverage based on the relevant
UWHC Antibiogram.74,75 (Class IIa, Level B)
21.1. See Treatment of Acute Pyelonephritis section for management approach.
21.2. Combination initial empiric therapy of a fluoroquinolone and ceftriaxone may be considered. (Class IIb, Level C)
22. Surgical intervention to correct an anatomic abnormality or alleviate the functional abnormality can be beneficial,
especially for severely ill patients.44,74,75 (Class IIb, Level B)
23. The duration of therapy for complicated UTI is prolonged, and should be seven days for a rapid response or ten to
fourteen days for delayed response.44,75 (Class I, Level A)

Treatment of Acute Pyelonephritis
24. General Principles
24.1. In patients with symptoms consistent with pyelonephritis, a urine culture should be obtained and sent for culture.
Treatment should be tailored as soon as possible to the infecting organism.48 (Class I, Level C)
24.1.1. Outpatient E.coli resistance at UWHC for calendar year 2011 was 10% to ciprofloxacin and 18% for
trimethoprim/sulfamethoxazole (data provided from UWMF clinics and EXCLUDES urology and
transplant clinics).
24.1.2. The current rate of inpatient, common Gram-negative urine isolates (Enterobacter cloacae, E. coli,
Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa) resistant
to TMP-SMX is 24%.
24.2. The choices below may be used for the empiric treatment of pyelonephritis. Definitive treatment guided by
susceptibility results may be considered. (Class IIa, Level B)
24.3. Nitrofurantoin and fosfomycin should not be used for the treatment of pyelonephritis as described in Section #14
and Section #18.67,73

25. Outpatient treatment options
25.1. Fluoroquinolone
25.1.1. Oral ciprofloxacin 500 to 750 mg PO BID for seven days or levofloxacin 500 to 750 mg PO daily for five
days, with or without an initial IV dose, is recommended for therapy not requiring hospitalization.48
(Class I, Level A)
25.1.1.1. Ciprofloxacin and levofloxacin doses may need to be adjusted for renal function. See
Renal Function-based Dose Adjustments – Adult – Inpatient Clinical Practice Guideline.
25.1.2. Ceftriaxone 1 gram IV or aminoglycoside (IV/IM), such as tobramycin or gentamicin 5 mg/kg, (may be
dose adjusted for renal function) may be reasonably substituted for the IV fluoroquinolone.48 (Class IIa,
Level B)

26. Inpatient treatment options
26.1. Based on current antibiogram resistance rates, initial empiric, strong consideration for combination
therapy may be reasonable. (Class IIb, Level C)
26.2. Ceftriaxone
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

14
26.2.1. Since the susceptibility prevalence is greater than 90%, treatment of pyelonephritis with ceftriaxone 1 g
IV every 24 hours is recommended.76 (Class IIa, Level B)
26.2.1.1. Two gram doses are unnecessary and not recommended. (Class III, Level C)
26.2.2. Treatment should continue until pathogen susceptibilities are known and targeted therapy initiated.48
(Class I, Level C)
26.3. Aminoglycosides
26.3.1. Once-daily tobramycin or gentamicin is effective for the treatment of pyelonephritis.48 (Class I, Level C)
26.3.1.1. Patients with recent exposure to fluoroquinolones or β-lactams may be considered for
empiric aminoglycoside therapy instead of a fluoroquinolone.77 (Class IIb, Level C)
26.3.1.2. Aminoglycoside dosing recommendations can be found in the Antibiotics for the Treatment
of Gram-negative Infections – Adult – Inpatient Clinical Practice Guideline.
26.3.2. Treatment should continue until pathogen susceptibilities are known or for up to five days, whichever is
shorter and targeted therapy initiated.48 (Class I, Level C)
26.3.3. Short courses of aminoglycosides (fewer than five days) are unlikely to result in nephrotoxicity when
dosed appropriate for renal function.78 (Class I, Level B)
26.4. Fluoroquinolones
26.4.1. Ciprofloxacin 400 mg IV or 500 to 750 mg PO every 12 hours for seven to ten days is appropriate and
recommended for patients unable to tolerate β-lactam therapy.79 (Class I, Level A)
26.4.1.1. Ciprofloxacin and levofloxacin doses may need to be adjusted for renal function. See
Renal Function-based Dose Adjustments – Adult – Inpatient Clinical Practice Guideline.
26.4.2. If fluoroquinolones are used empirically, a dose of either ceftriaxone or aminoglycoside may be
considered due to high levels of resistance.48 (Class IIb, Level C)
26.4.3. Levofloxacin is a reasonable alternative..
26.4.4. Moxifloxacin should NOT be used for the treatment of pyelonephritis or UTI due to low urinary
concentration.80 (Class III, Level B)
26.5. Trimethoprim/sulfamethoxazole (TMP-SMX)
26.5.1. TMP/SMX 160/800 mg BID for fourteen days is effective if the pathogen is known to be susceptible.79
(Class I, Level A)
26.5.1.1. TMP/SMX dose may need to be adjusted for renal function. See Renal Function-based
Dose Adjustments – Adult – Inpatient Clinical Practice Guideline.
26.5.2. If TMP/SMX is used empirically, a dose of either ceftriaxone or aminoglycoside is reasonable due to
levels of resistance of approximately 20%.48 (Class IIa, Level C)

27. Duration of therapy
27.1. The duration of therapy for acute pyelonephritis in otherwise healthy, adult women of seven to ten days is
effective, especially if a fluoroquinolone is used.81,82 (Class I, Level B)
27.2. Immunocompromised patients or patients with genitourinary devices may be considered for longer durations of
therapy. (Class IIb, Level C)
27.3. Oral TMP/SMX is recommended for fourteen days. 79 (Class I, Level A)
27.4. Oral β-lactam therapy is reasonable for ten to fourteen days.76 (Class IIa, Level B)

Diagnosis and Prevention of Catheter-Associated Urinary Tract Infection (CA-
UTI)
28. Unlike clean-catch specimens, no definitive quantitative number of bacteria defines significant bacteriuria. A
quantitative count of ≥103 CFU/mL should define significant bacteriuria in catheterized patients.35,44 (Class I, Level C)
29. Cultures should be obtained from a freshly placed catheter whenever possible.44 (Class I, Level B)
30. Cultures should NOT be obtained from the drainage bag.44 (Class III, Level C)
31. Screening for bacteriuria in asymptomatic patients is NOT recommended for either short-term catheterized patients or
long-term catheterized patients.44 (Class III, Level A)
32. Signs and symptoms usually associated with UTI are frequently absent in the catheterized patient.45 Foul smelling
and/or cloudy urine is not a reliable indicator of infection and should NOT be an indication alone for
antimicrobial therapy.38 (Class III, Level A)
33. Alternative symptoms, such as pain or discomfort over the kidney or bladder, fever, urinary spasticity, autonomic
hyperreflexia/dysreflexia, malaise, lethargy, or sense of unease can be beneficial for the diagnosis of CA-UTI.44 (Class
IIa, Level C)
34. Urinary catheters removal as soon as clinically appropriate is reasonable.2,4,5,83,84 (Class IIa, Level A)
34.1. Protocols allowing nursing staff to insert and remove urinary catheters without physician orders include Bladder
Management – Inpatient – Adult Protocol [26] and Indwelling Urinary Catheter Removal – Inpatient – Adult
Protocol [25].
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

15
35. While systemic antimicrobial administration reduced the rate of catheter-associated bacteriuria during the first four
days after catheterization, the incidence of bacteriuria normalized thereafter.85,86 Systemic antimicrobials resulted in
an increased incidence of resistant organisms and are NOT recommended. (Class III, Level B)
36. In all elderly patients, acute mental status change and functional decline are nonspecific clinical manifestations of
several circumstances, including, but not limited to dehydration, hypoxia, and polypharmacy adverse reactions. UTI
diagnosis in correlation with other signs of systemic inflammation, including leukocytosis may be considered.6 (Class
IIb, Level B)
36.1. It is may be reasonable to conclude UTI diagnosis in catheterized patients as a diagnosis of exclusion in the
absence of localized urinary tract findings 6 (Class IIb, Level C)
37. Elderly patients, especially those with dementia or indwelling Foley catheters, have high rates of bacteriuria and may
not have UTI symptoms.10 Diagnosis of sepsis of a urinary source is NOT recommended in the absence of urinary
symptoms because of bacteriuria. (Class III, Level C)
38. Antimicrobial prophylaxis at the time of urinary catheter removal can be beneficial for patients with short-term urinary
catheters (equal to or fewer than fourteen days).87 (Class IIa, Level A)
38.1. Nitrofurantoin, TMP/SMX, or ciprofloxacin or levofloxacin may be reasonable choices. (Class IIb, Level C)

Treatment in Special Populations
39. Peri-procedural (GU, OB/GYN) with bacteriuria
39.1. Treatment is recommended before transurethral resection of the prostate (TURP)88 (Class I, Level A) and before
other urologic procedures with anticipated mucosal bleeding.89 (Class IIa, Level B).
39.2. Generally, catheter irrigation with antiseptics have demonstrated no benefit reducing rates of catheter-
associated bacteriuria90,91; however, in men undergoing transurethral procedures, antiseptic irrigation with
chlorhexidine or povidone-iodine reduced the rate of catheter-associated bacteriuria by 22-24%.92,93 Irrigation in
select patient populations, such as those undergoing GU procedures can be beneficial. (Class IIa, Level B)
39.3. In patients with known urinary organisms and risk factors for surgical infection (as listed below), a single dose of
either ciprofloxacin 500 mg PO or TMP/SMX 160/800 PO may be given at the time of urinary catheter removal.44
(Class IIb, Level B)
39.3.1. Risk factors for surgical infection: advanced age, anatomic anomalies of the urinary tract, poor
nutritional status, smoking, chronic corticosteroid use, immunodeficiency, externalized catheters,
colonized endogenous/exogenous material, distant coexistent infection, prolonged hospitalization
39.4. In patients undergoing a GU surgical procedure, a urine culture is typically collected in advance.
39.4.1. If asymptomatic bacteriuria is found, the sample should be investigated for contamination and a repeat
sample ordered if time permits (more than three days until surgery). (Class IIb, Level C)
39.4.1.1. Contamination includes five or more epithelial cells or identification of skin flora.
39.4.2. When possible, treatment should be guided by culture susceptibility results (Class IIb, Level C)
39.4.3. Cultures positive for Lactobacillus, coagulase-negative Staphylococcus, or Staphylococcus non-
saprophyticus often do not require treatment and are considered skin or vaginal flora. (Class III, Level
C)
39.4.4. If a potential non-enterococci uropathogen is identified, treatment with nitrofurantoin 100 mg PO BID for
five days may be considered. (Class IIb, Level C)
39.4.4.1. Alternatives include TMP/SMX160/800mg PO BID for three days or ciprofloxacin 250 mg
PO BID for three days. (Class IIb, Level C)
39.4.4.2. If an enterococcus uropathogen is identified, treatment should be initiated with amoxicillin
500 mg TID for three days (two days prior to procedure and one day post-procedure) may
be considered. (Class IIb, Level C)
39.5. Doses may need to be adjusted for renal function. See Renal Function-based Dose Adjustments – Adult –
Inpatient Clinical Practice Guideline.

40. Urologic patients undergoing urodynamic testing
40.1. The use of antibiotics reduces the rate of bacteruria but does not reduce the rate of symptomatic UTI in patients
undergoing urodynamic testing. Therefore, it is reasonable to reserve prophylactic antibiotic use for patients
with risk factors for complications and avoid antibiotic use in patients with risk for adverse drug reaction.94 (Class
I, Level B)
40.1.1. Risk factors for complications associated with UTI following urodynamic testing include prolonged
catheter use and presence of prosthetic joint. (Class I, Level C)
40.1.2. If the patient has a catheter, performs intermittent self-catheterization, or uses a condom catheter,
prophylactic antibiotics prior to testing are reasonable. (Class IIa, Level C)
40.2. It is reasonable to choose antibiotics based on recent urine cultures. (Class IIb, Level C):
40.2.1. For cultures obtained within the past 30 days:
40.2.1.1. When possible, treatment guided by culture susceptibility results may be considered.
(Class IIb, Level C)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

16
40.2.1.2. If the culture includes enterococcus, not VRE, amoxicillin 500 mg PO TID for three days
(two days prior to procedure and one day post-procedure) may be reasonable. (Class IIb,
Level C)
40.2.1.3. In patients with penicillin intolerance, nitrofurantoin 100 mg PO BID for three days (two
days prior to procedure and one day post-procedure) may be reasonable. (Class IIb, Level
C)
40.2.2. If urine cultures were not obtained and resulted in the past 10 days:
40.2.2.1. First-line therapy may be considered as ciprofloxacin 250 mg PO BID for three days (two
days prior to procedure and one day post-procedure). (Class IIb, Level C)
40.2.2.2. Alternative therapy that may be considered includes TMP/SMX 160/800 mg PO BID or
nitrofurantoin 100 mg PO BID (both given for three days (two days prior to procedure and
one day post-procedure). (Class IIb, Level C)
40.2.3. Doses may need to be adjusted for renal function. See Renal Function-based Dose Adjustments –
Adult – Inpatient Clinical Practice Guideline.

Treatment of Specific Organisms
41. Mixed genitourinary (GU) flora
41.1. Non-catheterized patient
41.1.1. Mixed GU flora or Gardnerella vaginalis in the non-catheterized patient generally represent poor
specimen collection. Recollection should be considered rather than requesting microbiologic workup.
(Class IIb, Level C)
41.2. Catheterized patient
41.2.1. Mixed GU flora without a predominate organism generally represent colonization and do not require
treatment (Class IIb, Level C) unless the patient meets criteria listed in Treatment of Catheter-
associated Urinary Tract Infection.
41.2.2. Mixed GU flora with a predominating organism should be treated with antibiotics targeted to the
predominating organism and according to principles described in Treatment of Catheter-associated
Urinary Tract Infection.
41.2.2.1. It may be necessary to ask the microbiology lab to do sensitivity testing on the predominant
uropathogen if the culture has multiple organisms.

42. Coagulase-negative Staphylococcus
42.1. S. saprophyticus is the second-leading cause of UTI in young women.48
42.1.1. Amoxicillin/clavulanate 500/125 mg PO BID for seven days or amoxicillin 500 mg PO TID for seven to
ten days are reasonable first-line agents.48 (Class IIa, Level C)
42.1.2. Alternative agents that may be considered include ciprofloxacin 250 mg PO BID for three to seven
days, levofloxacin 250 mg daily for three to seven days, TMP/SMX 800/160 mg PO BID for seven days
or cephalexin 250 mg PO BID for seven to ten days (Class IIb, Level C).
42.1.3. Doses may need to be adjusted for renal function. See Renal Function-based Dose Adjustments –
Adult – Inpatient Clinical Practice Guideline.
42.2. Non-S.saprophyticus species, including coagulase-negative Staphylococcus, are rarely pathogens in the urinary
tract and generally represent poor specimen collection, unless collected from an indwelling catheter or
nephrostomy tube. Investigation into the quality of the sample may be reasonable to assess the likelihood of
pathogenicity. (Class IIb, Level C)
42.2.1. Vancomycin is may be considered as empiric therapy given the high rate of methicillin-resistance in
coagulase-negative Staphylococcus. (Class IIa, Level C)
42.2.2. Vancomycin dose should be adjusted based on renal function. See Intravenous Vancomycin Use –
Adult – Clinical Practice Guideline.

43. Staphylococcus aureus
43.1. Rarely does S. aureus cause ascending infection de novo.95-97
43.1.1. Patients with S. aureus cultured in the urine, especially without an indwelling catheter, should have
blood cultures drawn and a hematogenous route investigated. (Class I, Level A) S aureus may colonize
chronic indwelling catheters.
43.2. Empiric therapy with vancomycin may be reasonable and definitive treatment of S. aureus bacteriuria tailoring to
the antimicrobial susceptibility testing results may be considered. (Class IIb, Level C)
43.2.1. Vancomycin dose should be adjusted based on renal function. See Intravenous Vancomycin Use –
Adult – Clinical Practice Guideline.

44. Enterococcus spp. and vancomycin-resistant Enterococcus (VRE)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

17
44.1. Differentiation of colonization, asymptomatic bacteriuria, and UTI is important in the treatment of VRE
bacteriuria. Once colonizing the GI tract, eradication is not possible, and hence it may frequently appear in the
urinary system.44,98
44.1.1. VRE UTI is generally associated with urinary catheters and may be considered complicated UTI.98
(Class IIb, Level B)
44.1.2. It may be reasonable to treat for seven to fourteen days of therapy, with every effort made to remove
the catheter.44 (Class IIb, Level B)
44.2. Susceptibility testing should guide therapy, but generally ampicillin or amoxicillin are recommended as the drugs
of choice for ampicillin-susceptible Enterococcus.99 (Class I, Level B)
44.2.1. Piperacillin (as a component of Zosyn) is expected to have activity against ampicillin-susceptible
Enterococcus similar to amoxicillin and may be considered an alternative. (Class I, Level C)
44.2.1.1. Vancomycin may be considered for patients with severe β-lactam intolerance in patients
with non-VRE pathogen. (Class I, Level C)
44.2.2. Emerging evidence suggests that the resistance interpretation may not be important in the treatment of
VRE UTIs.100 It may be reasonable to consider treatment with amoxicillin regardless of susceptibility
reporting because the drug achieves very high urinary concentrations. (Class IIb, Level B)
44.3. Many patients with VRE bacteriuria are asymptomatic and not treating may be considered.98 (Class IIb, Level B)
44.3.1. Some asymptomatic patients who recently have had urinary catheters may be considered for one to
three doses of antibiotics after the catheter is removed. (Class IIb, Level C)
44.4. Alternative therapies for the treatment of VRE UTI include that may be considered are: nitrofurantoin,
fosfomycin, doxycycline, tetracycline, linezolid or levofloxacin, depending on susceptibilities. These are
preferred agents, if susceptible, as they are oral, safe, and cost effective. (Class I, Level C)
44.5. Daptomycin 4 mg/kg ideal body weight IV daily or linezolid 600 mg PO or IV every 12 hours may be considered
based on susceptibility testing and patient characteristics but are less preferred as they are IV administered,
may cause side effects, and are more expensive. (Class IIb, Level C)
44.6. Doses may need to be adjusted for renal function. See Renal Function-based Dose Adjustments – Adult –
Inpatient Clinical Practice Guideline.

45. Proteus spp.
45.1. Given the propensity of Proteus spp. to produce renal calculi and the difficulty of eradicating stones, extended
treatment durations (up to fourteen days) may be considered. (Class IIb, Level C)
45.2. In relapsing Proteus infection, urinary calculi evaluation is probably indicated.101 (Class IIa, Level C)

46. Anaerobic organisms
46.1. Anaerobic organisms are rarely pathogens in the urinary tract and the Microbiology Laboratory will not culture
urine for anaerobes.102
46.2. Empiric treatment against anaerobic organisms is not recommended.102 (Class III, Level B)

47. Gardnerella vaginalis, Ureaplasma urealyticum, and Mycoplasma hominis
47.1. These organisms may be isolated from the urine, but rarely are pathogenic. Special culture techniques are
necessary for isolation, and the Microbiology Laboratory should be contacted.103
47.2. Treatment may be considered in high-risk patients or patients with symptomatic UTI.103 (Class IIb, Level C)
47.3. Sample quality investigation may be considered to assess pathogenicity likelihood. (Class IIb, Level C)

48. Candida spp.
48.1. Therapy is not recommended, unless the patient is at high risk of dissemination (severely immunocompromised
patients with fever, renal transplant patients, patients with retained hardware in the genitourinary system,
patients undergoing a genitourinary surgical procedure).104 (Class I, Level C)
48.2. The catheter should be either removed or replaced prior to starting antifungal therapy whenever possible.104
(Class I, Level A)
48.3. In asymptomatic patients, imaging of the kidneys and collecting system to exclude abscess, fungal ball, or
urologic abnormality may be reasonable.104 (Class IIb, Level B)
48.3.1. Surgical debridement105, sterile water irrigation106, percutaneous debulking107, or streptokinase
irrigation106 can be beneficial. (Class IIa, Level B)
48.4. Candida glabrata was the most commonly identified organism in renal transplant patients at UWHC and most
patients were asymptomatic. Most candiduria resolved after removal of the indwelling bladder catheter within
one week of diagnosis.
48.4.1. In general, non-renal transplant patients, treatment with antifungals was not associated with improved
survival49 and therefore, antifungal treatment is not recommended (Class III, Level B).
48.4.1.1. “Treatment” should consist of catheter replacement. (Class I, Level C)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

18
48.4.1.2. Elimination of the predisposing factors (including obstruction, catheter presence) is
recommended first before antifungal therapy is initiated.104 (Class I, Level C)
48.4.2. However, in renal transplant patients with an indwelling Foley catheter, catheter replacement may be
considered before starting antifungal therapy. (Class IIb, Level C)
48.5. Treatment of Candida spp. cystitis should be with fluconazole 100-800 mg IV/PO daily for fourteen days.108-110
(Class I, Level A)
48.5.1. Non-fluconazole antifungals (itraconazole, voriconazole, and posaconazole) and the echinocandins
(micafungin, caspofungin, anidulafungin) are not effective for cystitis treatment due to low urinary
concentrations of active drug.104,110 (Class III, Level A)
48.5.2. High-dose fluconazole (400-800 mg or renal-equivalent dosing) is reasonable for the treatment of
Candida glabrata cystitis.110 (Class IIa, Level B)
48.5.3. Flucytosine is a highly effective anti-fungal agent for treatment of candiduria and may be considered
when fluconazole is not feasible (patient tolerance, drug-drug interactions, resistance, etc.) (Class IIb,
Level C)
48.5.3.1. Prolonged treatment may be limited by toxicity.111,112 Treatment should be limited to seven
to ten days due to risk of resistance when used as a single agent. (Class IIb, Level B)
48.5.4. Bladder irrigation with amphotericin-B 50 mg daily for seven to ten days may be considered in patients
with an indwelling catheter or for patients with fluconazole-resistant organism, such as Candida krusei
and Candida glabrata, but effectiveness is not well established.113 (Class IIb, Level B)
48.5.5. Intravenous treatment with amphotericin with conventional amphotericin product, not the liposomal
product is reasonable. (Class IIa, Level B)
48.5.5.1. The liposomal product does not achieve sufficient urinary concentrations.114 Short courses
of low-dose therapy leave amphotericin concentrations present in the urine for up to one
week after short-course therapy or longer for prolonged courses.115
48.6. Treatment of Candida spp. pyelonephritis with fluconazole 400 mg IV or PO daily for fourteen days is
reasonable.110 (Class IIa, Level B)
48.6.1. Echinocandins are highly metabolized in the liver with minimal active drug found in the urine and use for
UTI treatment is not routinely recommended. Use of an echinocandin for renal parenchyma treatment
may be considered under the direction of an Infectious Diseases specialist. (Class IIb, Level C)
48.6.2. The prolonged treatment course for fungal pyelonephritis limits the use of flucytosine due to toxic
effects of cumulative exposure. In patients requiring flucytosine, a dose of 25 mg/kg IV every 6 hours
with renal insufficiency adjustment (if necessary) is recommended.111 (Class I, Level B).
48.6.2.1. Due to the propensity for resistance development with long-term flucytosine monotherapy,
the addition of a second agent, such as conventional amphotericin B, can be beneficial.112
(Class IIa, Level B)
48.7. Candiduria in the critically ill patient may be an indication of disseminated candidiasis and prompt evaluation to
differentiate colonization from infection may be considered. (Class IIb, Level C)
48.7.1. Further treatment of invasive Candida spp. infections with subsequent candiduria should be guided by
Infectious Disease consult.
48.8. Antifungal doses may need to be adjusted for renal function. See Renal Function-based Dose Adjustments –
Adult – Inpatient Clinical Practice Guideline.

49. Corynebacterium urealyticum
49.1. C. urealyticum is common in the renal-transplant population116 and it is reasonable to consider in the presence
of ureteral stent, alkaline urine pH, previous UTI, or recent antibiotic therapy.117 (Class IIa, Level B)
49.1.1. If isolated in a non-renal transplant patient, sample quality investigation may be considered to assess
pathogenicity likelihood. (Class IIb, Level C)
49.2. C. urealyticum treatment with a glycopeptide-based (e.g. vancomycin) therapy is reasonable.116 (Class IIa, Level
B)
49.2.1. Vancomycin doses may need to be adjusted based on renal function. See Intravenous Vancomycin
Use – Adult – Clinical Practice Guideline.
49.3. C. urealyticum is frequently a cause of encrusting pyelitis Urology consultation may be considered. (Class IIb,
Level C)

Prevention Strategies
50. Antibiotic prophylaxis is not recommended but may be considered on a case-by-case basis in patients with recurrent
UTI. (Class III, Level C)
51. Vaginal/urine pH acidification may be considered to reduce the colonization of some uropathogenic bacteria.(Class
IIb, Level C)
51.1. Cranberry juice
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

19
51.1.1. Cranberry product manufacturing is unregulated by the FDA and products are considered an herbal
supplement by the UWHC Pharmacy and Therapeutics Committee. Therefore, cranberry products will
not be purchased by the UWHC pharmacy department or prescribed routinely to patients.
51.1.2. Clinical studies have shown no reduction in catheter-associated urinary tract infections with cranberry
products.118,119 The use of cranberry-based products effectiveness is not well established. (Class IIb,
Level B)
51.2. Methenamine
51.2.1. Methenamine use is contraindicated in patients with calculated creatinine clearance of below 50
mL/min due to decreased excretion and serum accumulation leading to toxicity.120 (Class III, Level B)
51.2.1.1. Methenamine activity is dependent on urine pH and urine more acidic that a pH of six with
the addition of ascorbic acid to increase the effectiveness of formaldehyde can be
beneficial.121 (Class IIa, Level B)
51.2.2. The use of methenamine in the catheterized patient is probably safe, but efficacy is reduced because of
limited dwell time in the bladder. Clinical studies have shown no reduction in catheter-associated
urinary tract infections.118 Therefore, the use of methenamine may be reasonable on a case-by-case
basis. (Class IIb, Level B)
51.3. Ascorbic acid
51.3.1. Ascorbic acid effectively acidifies urine pH and has demonstrated reductions in UTIs in pregnant
women and can be effective for UTI prophylaxis. 122 (Class IIa, Level B)
51.3.2. It is reasonable to consider ascorbic acid use with methenamine as ascorbic acid acidifies urine.121
(Class IIa, Level B)
52. Use of the contraceptive nonoxynol-9 is not recommended.21 (Class III, Level B)
53. Estrogen replacement therapy, especially vaginal hormone replacement therapy, may be considered to reduce the
recurrence of UTIs in women where hormone replacement therapy is otherwise indicated.123,124 (Class IIa, Level B)
53.1. This treatment should be considered for post-menopausal, as well as surgically and medically menopausal
women, unless otherwise contraindicated.124,125 (Class I, Level A)
54. Systemic antimicrobials (including antifungal agents) given at the time of catheter placement, replacement, or removal
is not recommended as fever associated with catheter manipulation is transient, unless the patient has a genitourinary
procedure with risk factors listed in Treatment in Special Populations.126,127 (Class III, Level B)
55. Probiotics (lactobacilli preparations) have been studied for prevention of UTI and provided no clear benefit.128
Probiotic use for UTI prophylaxis is not recommended. (Class III, Level A)

Therapeutic Monitoring Strategies
56. It is not recommended to perform repeat urinalysis to confirm clinical or microbiologic response. (Class III, Level C)
57. Bacteriologic response should occur within 48 hours for cystitis and within 72 hours for complicated UTI or
pyelonephritis. Fever is common for 72 hours in patients with complicated UTI and pyelonephritis.
57.1. If no response occurs by 48-72 hours, alternative therapy may be considered. (Class IIb, Level C)
57.2. In genitourinary procedure patients with known urinary organisms and risk factors for surgical infection (listed
below), a single dose of either ciprofloxacin 500 mg PO or TMP/SMX 160/800 mg PO at the time of urinary
catheter removal is reasonable.129 (Class IIa, Level B)
57.2.1. Risk factors for surgical infection: advanced age, anatomic anomalies of the urinary tract, poor
nutritional status, smoking, chronic corticosteroid use, immunodeficiency, externalized catheters,
colonized endogenous/exogenous material, distant coexistent infection, prolonged hospitalization.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

20
Figure 1. Diagnosis of UTI in the 18-65 year old, non-catheterized patient

Does the patient have signs or
symptoms consistent with UTI?
Signs or symptoms of UTI
ξ Dysuria
ξ Increased frequency or urgency
ξ Suprapubic pain/tenderness
No Yes
Vaginal symptoms should
prompt alternative diagnosis
Paraplegic patients may only present with
fever, increased spasticity, andor
antonomic dysreflexia
Obtain Urinalysis*
Footnotes
* In general, the UA is a poor predictor of UTI and
must be combined with clinical manifestations of
consistent with UTI
* In patients with recent (<72 hrs) catheterization with
persistent asymptomatic bacteriuria, consider single dose
of ciprofloxacin or TMP/SMX
Notes about interpreting the UA
ξ Urine color/clarity should not be used alone to
diagnosis or start antimicrobial therapy
ξ leukocyte esterase test has high sensitivity and
specificity (80-90% and 95-98%, respectively);
however a positive leukocyte esterase alone is NOT
recommended for diagnosis of UTI
ξ presence of bacteria in the urine without UTI
symptoms is NOT recommended for the diagnosis of
UTI
Fever, flank pain, sepsis or other
suspicion for pyelonephritis?
Significant Bacteruria?
Voided specimen: ≥ 10
5
cfu/mL of ≤ 2 species of organisms
Straight cath: ≥ 10
2
cfu/mL of any number of organisms
Asymptomatic Bacteriuria
ξ In general, most pts do not require antibiotic
treatment
ξ Asymptomatic bacteriuria incidence
increases with age
ξ Antibiotic treatment should only be made
after the identification of urine as the most
likely source and certain pt populations
(pregnancy, urinary stents, and recent renal
transplant recipients)
In absence of s/sx consistent with UTI, consider
alternative diagnosis
Tables 4 and 5:
Agents for the
treatment of
pyelonephritis
Structurally abnormal, neurologically
damaged urinary tract?
Male?
Renal calculi present?
Table 3. Agents for
the treatment of
complicated UTI
and cystitis
YesNo
Yes
No
Uncomplicated UTI?
Table 2. Agents for
the treatment of
uncomplicated UTI
Signs and symptoms NOT
consistent with UTI
Signs and symptoms
CONSISTENT with UTI

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

21
Figure 2. Diagnosis of UTI in the elderly and/or institutionalized catheterized and non-catheterized patient
Does the patient have an indwelling catheter?
¥
Signs or symptoms of UTI
ξ Dysuria
ξ Increased frequency or urgency
ξ Suprapubic pain/tenderness
No Yes
* Paraplegic patients may only present with fever,
increased spasticity, and/or antonomic dysreflexia
* Vaginal symptoms should prompt alternative
diagnosis
* In patients with recent (<72 hrs) catheterization
with persistent asymptomatic bacteriuria, consider
single dose of ciprofloxacin or TMP/SMX
Obtain Urinalysis from a freshly
placed catheter*

Is the patient experiencing acute mental status
(AMS) changes?
No Yes
ξ AMS change and functional decline are nonspecific
clinical manifestations of several circumstances,
including, but not limited to dehydration,
hypoxia,dementia, and polypharmacy adverse
reactions.
ξ Falls without localizing urinary s/sx were NOT
associated with bacteriuria or pyuria.
ξ Diagnosis of UTI should be correlated with other
signs of systemic inflammation, including
leukocytosis.
ξ Diagnosis of urosepsis is NOT recommended in the
absence of urinary symptoms because of bacteriuria
Diagnosis of
catheter-
associated UTIª
2 criteria must be present for diagnosis of UTI
Criteria 1: ≥ 1 sign or symptom subcriteria:
ξ acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis,
or prostate OR fever or leukocytosis AND localized urinary tract criteria (acute
CVA pain/tenderness, suprapubic pain, gross hematuria, new or increased
incontinence, urinary frequency or urgency)
Criteria 2: one of the following microbiologic subcriteria:
ξ ≥ 10
5
cfu/mL of ≤ 2 species of microorganisms in voided culture OR ≥ 10
2
cfu/
mL of any number of microorganisms in a straight cath culture
Obtain Urinalysis*
2 criteria must be present for diagnosis of UTI
Criteria 1: ≥1 signs or symptom subcriteria
ξ Fever, rigors, or new-onset hypotension, with no alternative site of
infection OR acute change in mental status or acute functional
decline, with no alternative diagnosis
AND leukocytosis OR new-
onset suprapubic pain or CVA pain/tenderness OR Purulent
discharge from around the catheter or acute pain, swelling, or
tenderness of the testes, epididymis, or prostate
Criteria 2 – catheter specimen culture with ≥10
3
cfu/mL of any
organism(s)

Notes about interpreting the UA
ξ In general, the UA is a poor predictor of UTI and must be
combined with clinical manifestations before the diagnosis of
UTI is made or antimicrobial therapy initiated.
ξ AMS changes and
change in urine character (color or odor) were
each independently associated with bacteriuria plus pyuria in patients
with clinically suspected UTI
ξ A good specimen has less than 5 epithelial cells per LPF. Poor
specimens may be considered for recollection
Notes about interpreting the UA
ξ In general, the UA is a poor predictor of UTI and must be combined with
clinical manifestations before the diagnosis of UTI is made or antimicrobial
therapy initiated.
ξ Foul smelling and/or cloudy urine is not a reliable indicator of infection in
catheterized patients and should NOT be an indication alone for testing the urine
or starting antimicrobial therapy
Significant Bacteruria?
Voided specimen: ≥ 10
5
cfu/mL of ≤ 2 species of organisms
Straight cath: ≥ 10
2
cfu/mL of any number of organisms
Significant Bacteruria?
≥10
2
cfu/mL of any organism(s) should
define clinical significant bacteriuria
Yes
In the absence of a clear alternative source of infection, fever
or rigors with a positive urine culture result in the
noncatheterized resident OR acute confusion, pain or
discomfort over the kidney or bladder, fever, spasticity,
autonomic dysreflexia, malaise, or lethergy in the catheterized
patient will often be treated as UTI. However, evidence
suggests that most of these episodes are likely not due to
infection of the urinary tract
Positive Urine
Culture
§
No Yes
Positive Urine
Culture
§
Diagnosis of complicated
UTI or pyelonephritis
Positive blood culture
isolate same as urine
isolate with no other source
of infection?
Table 3, 4, and 5
for treatment
Remove catheter
(if not completed
already) and
assess need for
further treatment
Remove catheter (if appropriate) and
assess need for treatment
Start empiric therapy based on
acuity of illness (Tables 3, 4, 5)

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

22
Figure 2 Footnotes
* Signs and symptoms usually associated with UTI are frequently absent in the catheterized patient. Foul
smelling and/or cloudy urine is not a reliable indicator of infection and should NOT be an indication
alone for testing the urine or starting antimicrobial therapy.
¥
Residents with intermittent or condom catheters are at lower risk for UTI and should be considered in the same
risk category as those with no indwelling catheter.
€ Catheter specimens should be collected following replacement of the catheter if the current catheter has been in
place >14 days.
§
Reference Table 6 for guidance regarding interpretation of some organisms.
ª Diagnosis of UTI in the catheterized patient should always be a diagnosis of exclusion in the absence of
localized urinary tract findings.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

23
Figure 3. Urinary tract infection management in abdominal solid organ transplant patients
Asymptomatic bacteriuria Symptomatic UTIA
Clinical
Features No urinary symptoms
Cystitis symptoms
ξ dysuria
ξ urinary frequency
ξ urinary urgency
ξ elevated creatinine
Pyelonephritis symptoms
ξ cystitis symptoms
ξ suprapubic pain
ξ pain at graft site
ξ costovertebral angle tenderness or pain
ξ fever, malaise
Urinalysis and
Culture
Findings
“Positive” Urinalysis findings: > 5 WBC/HPF, < 2 squamous epithelial cells/HPF, bacteria present
Pyuria (>5 WBC) or bacteriuria does not confirm diagnosis of UTI. Absence of pyuria or bacteriuria questions the diagnosis of UTI.
Urinalysis collections with squamous epithelial cells present consider straight catheterization specimen to increase quality.

“Significant” bacterial growth on urine culture:
ξ Men: clean-catch urine specimen with >105 CFU/mL of a single organism
ξ Women: two clean-catch urine specimens more than 24 hours apart with >105 CFU/mL of a single organism
ξ Straight catheterization sample: >102 CFU/mL of a single organism

Relative organism frequency
70% of uropathogens are Gram-negative organisms, most frequently E. coli

Common nonpathogenic bacteria for which no treatment is necessary
ξ Non-saprophyticus, coagulase-negative Staphylococcus species (unless hardware is in place)
ξ Lactobacillus species
ξ Gardnerella vaginalis
ξ Corynebacterium non-urealyticum
ξ Mixed flora may represent poor collection methods
Management

<3 months post-transplant
ξ No empiric antibiotics
ξ Await final culture results to start
therapy of five to seven day
antibiotic course

>3 months post-transplant
ξ No treatment unless associated
rise in creatinine
Mild cystitis without concern for systemic infection
ξ If GFR >40 mL/min, nitrofurantoin 100 mg PO BID for 7 days
ξ If GFR <40 mL/min or concern for drug-resistant isolates, fosfomycin 3 g PO x 1 dose
ξ Deescalate to narrowest spectrum antimicrobial based on culture results when available

Moderate/severe infection or mild cystitis with concern for possible pyelonephritis or urinary
hardware in place (e.g. stents, nephrostomy tubes)
ξ Empiric ciprofloxacin 500 mg PO BIDB
ξ Treat for 14 days
ξ For patients with previous culture history, use historical results to guide empiric therapy
ξ Deescalate to narrowest spectrum antimicrobial based on culture results when available

Patients allergic or intolerant to the above agents
ξ Amoxicillin/clavulanic acid 875 mg PO BIDB
ξ 3rd generation oral cephalosporin (cefpodoxime 200 mg BID)B
ξ TMP/SMX DS (160/800 mg) BID (although likelihood of resistance is increased if previously
received for prophylaxis post-transplant)B
A
In cases of multiple symptomatic UTIs, patients may require referral to Urology and/or Infectious Disease
B Doses should be adjusted for renal function. See Renal Function-based Dose Adjustments – Adult – Inpatient Clinical Practice Guideline
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

24
Table 1. Agents for the treatment of uncomplicated UTI/cystitisA,B
Drug Dose and Duration Notes
EM
PI
RI
C
Th
e
ra
p
ie
s

Nitrofurantoin 100 mg PO BID x 5 days
CrCL <30mL/min: contraindicated
CrCL 30-50 mL/min: use with caution and
monitor for symptom resolution
Not for use in pyelonephritis
Trimethoprim/
SulfamethoxazoleC
160/800 mg PO BID
x 3 days
Caution is advised in patients receiving for
prophylaxis since likelihood of resistance is
high
CefpodoximeC,D 100 mg PO BID x 7 days Consider change to narrow spectrum β-
lactam when susceptibilities are known
Ciprofloxacin,
LevofloxacinC
Ciprofloxacin: 250 mg PO
BID x 3 days

Levofloxacin: 250 mg PO
daily x 3 days
Caution is advised due to increased rates of
Clostridium difficile infection and other super-
infections associated with fluoroquinolone
use

Moxifloxacin should not be used for
treatment due to low urinary concentrations
DE
F
IN
IT
IV
E
T
h
er
ap
ie
s
AmoxicillinC 500 mg PO BID x 7 days
Active against ampicillin-susceptible
Enterococcus spp.
Use when susceptibilities are known, not for
empiric use
CephalexinC,D 500 mg PO BID x 7 days Use when susceptibilities are known, not for
empiric use
Fosfomycin 3 g PO ONCE
Susceptibility testing is limited based on FDA
approval; however, E.coli resistance rates
are low
Has in-vitro activity against VRE
(vancomycin-resistant Enterococcus spp.)
and ESBL (extended spectrum β-lactamase
producing bacteria) organisms
Not for use in pyelonephritis
A These agents are listed in their preferred order. The optimal therapy depends on many factors and each
medication has risks and benefits which must be considered when choosing treatment.
B Definitive therapy should be guided by susceptibility testing and results.
C Doses should be adjusted based on renal function. See Renal Function-based Dose Adjustments –
Adult – Inpatient Clinical Practice Guideline.
D Cefdinir, Cefixime, Cefuroxime, or Cefpodoxime may be considered as alternative if necessary for
insurance coverage or if for other clinical reason.

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

25
Table 2. Agents for the treatment of complicated UTI/cystitisA,B
Moderately ill, no history of resistant uropathogens, no recent fluoroquinolone use, local
resistance rates exceed 10%
CiprofloxacinC 500 mg PO BID May start therapy with 400 mg IV Q12H until
patient is tolerating orals
Moderately ill, with a history of resistant uropathogens or recent fluoroquinolone use
Ceftriaxone
+/- ciprofloxacinC
1 g IV Q24H
+/- IV or PO ciprofloxacin BID
Severely ill patients should be treated following the recommendations in Table 4. Pyelonephritis
A
In general, empiric treatment should have a broader spectrum of antibiotics followed by a tailoring of
therapy based on culture and susceptibility results. Surgical intervention to correct the anatomic
abnormality or alleviate the functional abnormality should be considered, especially for severely ill
patient.
B The duration of therapy for complicated UTI is prolonged, generally 7 days for a rapid response or 10-14
days for delayed response.
C Doses should be adjusted based on renal function. See Renal Function-based Dose Adjustments –
Adult – Inpatient Clinical Practice Guideline.

Table 3. Agents for the treatment of acute pyelonephritis – outpatientA,B
Drug Dose and Duration Notes
CiprofloxacinC 500 mg PO BID x 7-10 days
Give first dose ciprofloxacin/levofloxacin 400/500mg IV
ONCE LevofloxacinC 750 mg PO daily x 5 days or
500 mg PO daily x 7-10 days
Ceftriaxone 1 g IV Q24H
Alternative to one-time dose of IV fluoroquinolone Tobramycin or
GentamicinD
5 mg/kg (adjusted body
weight) IV Q24H
A A urine culture should be collected and sent for culture in all patients with suspected pyelonephritis.
Empiric therapy should be tailored as soon as possible to the infecting organism.
B Nitrofurantoin and fosfomycin should not be used for the empiric treatment of pyelonephritis with
suspected bacteremia/sepsis because they do not achieve sufficient systemic bloodstream
concentrations.
C
Doses should be adjusted based on renal function. See Renal Function-based Dose Adjustments –
Adult – Inpatient Clinical Practice Guideline.
D Doses should be adjusted based on renal function. See Antibiotics for the Treatment of Gram-negative
Infections – Adult – Inpatient Clinical Practice Guideline.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

26
Table 4. Agents for the treatment of acute pyelonephritis – inpatientA,B,C,D
Drug Dose and Duration Notes
Ceftriaxone 1 g IV Q24H x 10-14 days Continue therapy until susceptibility is known.
Tobramycin or
GentamicinE
5 mg/kg (adjusted body
weight) IV Q24H
Consider in patients with recent fluoroquinolone or β-
lactam use
Short courses of therapy (< 5 days) are unlikely to
result in nephrotoxicity
CiprofloxacinE 400 mg IV BID x 7-10
days
If used empirically, a dose of either ceftriaxone or
aminoglycoside should be considered due to high rates
of resistance
Trimethoprim/
SulfamethoxazoleF
160/800 mg PO BID x 14
days (may be given IV if
unable to take oral
medication)
If used empirically, a dose of either ceftriaxone or
aminoglycoside should be considered due to high rates
of resistance.
A A urine culture should be collected and sent for culture in all patients with suspected pyelonephritis.
Empiric therapy should be tailored as soon as possible to the infecting organism.
B Nitrofurantoin and fosfomycin should not be used for the empiric treatment of pyelonephritis with
suspected bacteremia/sepsis because they do not achieve sufficient systemic bloodstream
concentrations.
C
Immunocompromised patients or patients with GU devices may be considered for longer duration of
therapy.
D These agents are listed in their preferred order. The optimal therapy depends on many factors and each
medication has risks and benefits which must be considered when choosing treatment.
E
Doses should be adjusted based on renal function. See Antibiotics for the Treatment of Gram-negative
Infections – Adult – Inpatient Clinical Practice Guideline.
F Doses should be adjusted based on renal function. See Renal Function-based Dose Adjustments – Adult
– Inpatient Clinical Practice Guideline.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

27
Table 5. Treatment of specific organisms
Organism Treatment Option Notes
Mixed genitourinary flora in non-
catheterized patient
Recollection Generally represent poor specimen collection. Suggest
recollection.
Mixed genitourinary flora in
catheterized patient
Target predominate
organism
If no predominating organism, likely colonization.
With predominating organism, tailor treatment to said organism.
Staphylococcus saprophyticus
Amoxicillin/clavulanate
500/125 mg PO BID x 7
days OR
Amoxicillin 500 mg PO
TID x 7-10 daysA
Second leading cause of UTI in young women.

Alternative regimens include ciprofloxacin 250 mg PO BID x 3-7
days, trimethoprim/sulfamethoxazole 160/800 mg PO BID x7
days, or cephalexin 250 mg PO BID x 7-10 days.A
Coagulase-negative
Staphylococcus
(non-saprophyticus)
Vancomycin IVB
Goal trough 10-15
Rarely pathogens in the urinary tract and generally represent poor
specimen collection, unless from indwelling catheter.
Staphylococcus aureus Tailored to antimicrobial
susceptibilities
Rarely causes ascending infection de novo. Patients should have
blood cultures drawn and hematogenous route investigated.
Enterococcus spp.
(ampicillin-susceptible)
Amoxicillin 500 mg PO
BID x 3-7 daysA
Susceptibility testing should guide final therapy. Ampicillin
susceptibility predicts piperacillin activity.

Alternative regimen of vancomycin for patients with true penicillin
or β-lactam allergy.
Enterococcus spp.
(vancomycin-resistant)
Often asymptomatic and
no treatment required.
Tailor to antimicrobial
susceptibilities.

Duration of therapy:
Remove catheter: 1-3
days
Without catheter: 7-14
days
Frequent colonizer or cause of asymptomatic bacteriuria. Once GI
colonization, eradication Is not possible and hence it may
frequently appear in the urinary system.

Alternative regimens (in preferential order) include nitrofurantoin,
fosfomycin, doxycycline, tetracycline, daptomycin 4mg/kg,
linezolid PO, or tigecycline.
Proteus spp. Tailor to antimicrobial
susceptibilities x 14 days
High propensity to produce renal calculi. Relapsing Proteus
infections should prompt an evaluation for urinary calculi.
Anaerobic organisms Empiric treatment NOT
recommended
Rarely pathogens in the urinary tract and the microbiology lab will
not routinely perform cultures.
Gardnerella vaginalis Recollection May be isolated from urine but rarely pathogenic. Investigate
sample quality to assess pathogenicity.
Ureaplasma urealyticum Recollection/special
collection
May be isolated from urine but rarely pathogenic. Investigate
sample quality to assess pathogenicity.
Mycoplasma hominis Recollection/special
collection
May be isolated from urine but rarely pathogenic. Investigate
sample quality to assess pathogenicity.
Candida albicans Fluconazole 100-400 mg PO daily x14 daysA Remove or replace catheter if appropriate.
Candida glabrata
Low risk Remove or replace catheter if appropriate.
Candida glabrata
High risk (includes severely
immunocompromised and
febrile; renal transplant; patients
with retained genitourinary
hardware; and patients
undergoing genitourinary
procedure)
Remove or replace
catheter.

Treatment with
fluconazole 400-800 mg
IV/PO dailyA
Most common organism in UW renal transplant patients; however,
most were asymptomatic.

Imaging of the kidneys and collection system should be
performed

Non-fluconazole antifungals and echinocandins should not be
used for treatment.

Bladder irrigation with amphotericin B 50 mg daily x 7-10 days.
Corynebacterium urealyticum Vancomycin IV
B

Goal trough 10-15
Common in renal transplant population, otherwise investigate
sample quality to assess pathogenicity.

Consider urology consultation as this organism may cause
encrusting pyelitis.
A Doses should be adjusted based on renal function. See Renal Function-based Dose Adjustments – Adult –
Inpatient Clinical Practice Guideline.
B Vancomycin should be adjusted based on renal function. See Intravenous Vancomycin Use – Adult – Clinical
Practice Guideline.

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

28
Table 6. Prevention Strategies
Therapy Notes
Antimicrobial Agents Discouraged due to concern for development of antimicrobial
resistance. May be considered on a case-by-case basis.
Cranberry Juice
Unregulated product by the FDA, therefore, manufacturing standards
and quality vary.
No data to support reduction of catheter-associated UTI.
Methenamine
Contraindicated in patients with CrCL <50mL/min.
Urine pH should be measured and be maintained <6.
Efficacy depends on dwell time and therefore use in catheterized
patients is unknown.
Ascorbic Acid
Reduces pH of urine and has shown to reduce UTIs in pregnant
women.
Consider use with methenamine
Vaginal Estrogen
Consider only when hormone replacement therapy is indicated.
Consider in post-menopausal, surgically and medically menopausal
women.
Vaginal pH reduction May be considered to reduce the colonization of some uropathogenic
bacteria.
Nonoxynol-9 NOT recommended.
Lactobacillus probiotics NOT recommended.



Table 7. Candidates for screening UrinalysisA
UA screening suggested/recommended UA screening NOT recommended

ξ 18-65 yo symptomatic women without a
history of UTI
ξ Pregnant women early in pregnancy
ξ Early renal transplant recipients

ξ 18-65 yo symptomatic women with frequent
recurrences and prior lab confirmed UTI
ξ Asymptomatic elderly, community dwelling
patients
ξ Asymptomatic LTCF or institutionalized
patients
ξ Asymptomatic diabetic women

A
Because of the risk of iatrogenic UTI, catheterization is not recommended. However, in patients where the quality of
sample has or may be compromised (>5 epithelial cells), catheterization may be considered.



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

29
UWHealth Implementation
Benefits/Harms of Implementation
ξ Implementation of this guideline will standardize the care of patients treated for urinary tract infections.
ξ Utilization of this guideline drives prescribing towards narrow spectrum agents. This reduces antimicrobial
pressure on the bacterial biomass and reduces the emergence of bacterial resistance.

Implementation Strategy
ξ This guideline will be disseminated to clinical staff and available electronically.
ξ This guideline will serve as a resource for clinical inservices.

Implementation Tools/Plan
ξ This clinical practice guideline will be posted for reference in UConnect.
ξ Links to this clinical practice guideline will be available electronically at point of use sites.

Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and treatment of patients.
This Clinical Practice Guideline outlines the preferred approach for most patients. It is not intended to replace a
clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the
clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate
approach to a problem.

References
1. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America
guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clinical infectious diseases
: an official publication of the Infectious Diseases Society of America. Mar 1 2005;40(5):643-654.
2. Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized
medical patients. Archives of internal medicine. Jul 10 1995;155(13):1425-1429.
3. Wong ES. Guideline for prevention of catheter-associated urinary tract infections. American journal of
infection control. Feb 1983;11(1):28-36.
4. Gardam MA, Amihod B, Orenstein P, Consolacion N, Miller MA. Overutilization of indwelling urinary
catheters and the development of nosocomial urinary tract infections. Clinical performance and quality
health care. Jul-Sep 1998;6(3):99-102.
5. Munasinghe RL, Yazdani H, Siddique M, Hafeez W. Appropriateness of use of indwelling urinary catheters
in patients admitted to the medical service. Infection control and hospital epidemiology : the official journal of
the Society of Hospital Epidemiologists of America. Oct 2001;22(10):647-649.
6. Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities:
revisiting the McGeer criteria. Infection control and hospital epidemiology : the official journal of the Society
of Hospital Epidemiologists of America. Oct 2012;33(10):965-977.
7. Juthani-Mehta M, Quagliarello V, Perrelli E, Towle V, Van Ness PH, Tinetti M. Clinical features to identify
urinary tract infection in nursing home residents: a cohort study. Journal of the American Geriatrics Society.
Jun 2009;57(6):963-970.
8. Nicolle LE. Urinary tract infections in the elderly. Clin. Geriatr. Med. Aug 2009;25(3):423-436.
9. Nicolle LE. Symptomatic urinary tract infection in nursing home residents. Journal of the American Geriatrics
Society. Jun 2009;57(6):1113-1114.
10. Nicolle LE. Urinary tract infections in long-term-care facilities. Infection control and hospital epidemiology :
the official journal of the Society of Hospital Epidemiologists of America. Mar 2001;22(3):167-175.
11. Cunha BA, Schoch PE, Hage JR. Nitrofurantoin: preferred empiric therapy for community-acquired lower
urinary tract infections. Mayo Clinic proceedings. Mayo Clinic. Dec 2011;86(12):1243-1244; author reply
1244.
12. Gilbert DN. Urinary tract infections in patients with chronic renal insufficiency. Clinical journal of the
American Society of Nephrology : CJASN. Mar 2006;1(2):327-331.
13. Bains A, Buna D, Hoag NA. A retrospective review assessing the efficacy and safety of nitrofurantoin in
renal impairment. Can Param J. 2009;142:248-252.
14. Geerts AF, Eppenga WL, Heerdink R, et al. Ineffectiveness and adverse events of nitrofurantoin in women
with urinary tract infection and renal impairment in primary care. Eur. J. Clin. Pharmacol. Sep
2013;69(9):1701-1707.
15. Tricoci P, Allen J, Kramer J, Califf R, Smith S. Scientific evidence underlying the ACC/AHA Clinical Practice
Guidelines. . JAMA. 2009;301(8):831-841.
16. Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. The American
journal of medicine. Jul 8 2002;113 Suppl 1A:5S-13S.
17. Cai T, Mazzoli S, Mondaini N, et al. The Role of Asymptomatic Bacteriuria in Young Women With Recurrent
Urinary Tract Infections: To Treat or Not to Treat? Clinical infectious diseases : an official publication of the
Infectious Diseases Society of America. Jul 5 2012.
18. Ronald AR, Pattullo AL. The natural history of urinary infection in adults. The Medical clinics of North
America. Mar 1991;75(2):299-312.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

30
19. Spach DH, Stapleton AE, Stamm WE. Lack of circumcision increases the risk of urinary tract infection in
young men. JAMA : the journal of the American Medical Association. Feb 5 1992;267(5):679-681.
20. Turck M, Goffe B, Petersdorf RG. The urethral catheter and urinary tract infection. The Journal of urology.
Dec 1962;88:834-837.
21. Hooton TM, Scholes D, Hughes JP, et al. A prospective study of risk factors for symptomatic urinary tract
infection in young women. The New England journal of medicine. Aug 15 1996;335(7):468-474.
22. Turck M, Browder AA, Lindemeyer RI, Brown Nk Anderson KN, Petersdorf RG. Failure of prolonged
treatment of chronic urinary-tract infections with antibiotics. The New England journal of medicine. Nov 15
1962;267:999-1005.
23. Baldassarre JS, Kaye D. Special problems of urinary tract infection in the elderly. The Medical clinics of
North America. Mar 1991;75(2):375-390.
24. Boscia JA, Kaye D. Asymptomatic bacteriuria in the elderly. Infectious disease clinics of North America. Dec
1987;1(4):893-905.
25. Nordenstam GR, Brandberg CA, Oden AS, Svanborg Eden CM, Svanborg A. Bacteriuria and mortality in an
elderly population. The New England journal of medicine. May 1 1986;314(18):1152-1156.
26. Abrutyn E, Mossey J, Berlin JA, et al. Does asymptomatic bacteriuria predict mortality and does
antimicrobial treatment reduce mortality in elderly ambulatory women? Annals of internal medicine. May 15
1994;120(10):827-833.
27. Nicolle LE. Urinary tract infection in geriatric and institutionalized patients. Current opinion in urology. Jan
2002;12(1):51-55.
28. Frank U, Kleissle EM, Daschner FD, et al. Multicentre study of antimicrobial resistance and antibiotic
consumption among 6,780 patients with bloodstream infections. European journal of clinical microbiology &
infectious diseases : official publication of the European Society of Clinical Microbiology. Dec
2006;25(12):815-817.
29. Tacconelli E, De Angelis G, Cataldo MA, Pozzi E, Cauda R. Does antibiotic exposure increase the risk of
methicillin-resistant Staphylococcus aureus (MRSA) isolation? A systematic review and meta-analysis. The
Journal of antimicrobial chemotherapy. Jan 2008;61(1):26-38.
30. Rahal JJ, Urban C, Segal-Maurer S. Nosocomial antibiotic resistance in multiple gram-negative species:
experience at one hospital with squeezing the resistance balloon at multiple sites. Clinical infectious
diseases : an official publication of the Infectious Diseases Society of America. Feb 15 2002;34(4):499-503.
31. Burke JP. Antibiotic resistance--squeezing the balloon? JAMA : the journal of the American Medical
Association. Oct 14 1998;280(14):1270-1271.
32. Stevens V, Dumyati G, Fine LS, Fisher SG, van Wijngaarden E. Cumulative antibiotic exposures over time
and the risk of Clostridium difficile infection. Clinical infectious diseases : an official publication of the
Infectious Diseases Society of America. Jul 1 2011;53(1):42-48.
33. ACOG Practice Bulletin No. 91: Treatment of urinary tract infections in nonpregnant women. Obstetrics and
gynecology. Mar 2008;111(3):785-794.
34. Epp A, Larochelle A, Lovatsis D, et al. Recurrent urinary tract infection. Journal of obstetrics and
gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC. Nov
2010;32(11):1082-1101.
35. Stark RP, Maki DG. Bacteriuria in the catheterized patient. What quantitative level of bacteriuria is relevant?
The New England journal of medicine. Aug 30 1984;311(9):560-564.
36. Sugimura T, Arnold E, English S, Moore J. Chronic suprapubic catheterization in the management of
patients with spinal cord injuries: analysis of upper and lower urinary tract complications. BJU international.
Jun 2008;101(11):1396-1400.
37. Foley A, French L. Urine clarity inaccurate to rule out urinary tract infection in women. Journal of the
American Board of Family Medicine : JABFM. Jul-Aug 2011;24(4):474-475.
38. Nicolle LE. The chronic indwelling catheter and urinary infection in long-term-care facility residents. Infection
control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America.
May 2001;22(5):316-321.
39. Pappas PG. Laboratory in the diagnosis and management of urinary tract infections. The Medical clinics of
North America. Mar 1991;75(2):313-325.
40. Bent S, Saint S. The optimal use of diagnostic testing in women with acute uncomplicated cystitis. The
American journal of medicine. Jul 8 2002;113 Suppl 1A:20S-28S.
41. Deville WL, Yzermans JC, van Duijn NP, Bezemer PD, van der Windt DA, Bouter LM. The urine dipstick test
useful to rule out infections. A meta-analysis of the accuracy. BMC urology. Jun 2 2004;4:4.
42. Van Nostrand JD, Junkins AD, Bartholdi RK. Poor predictive ability of urinalysis and microscopic
examination to detect urinary tract infection. American journal of clinical pathology. May 2000;113(5):709-
713.
43. Loeb M, Brazil K, Lohfeld L, et al. Effect of a multifaceted intervention on number of antimicrobial
prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised
controlled trial. BMJ. Sep 24 2005;331(7518):669.
44. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated
urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases
Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of
America. Mar 1 2010;50(5):625-663.
45. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective
study of 1,497 catheterized patients. Archives of internal medicine. Mar 13 2000;160(5):678-682.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

31
46. Loeb M, Bentley DW, Bradley S, et al. Development of minimum criteria for the initiation of antibiotics in
residents of long-term-care facilities: results of a consensus conference. Infection control and hospital
epidemiology : the official journal of the Society of Hospital Epidemiologists of America. Feb 2001;22(2):120-
124.
47. Hartley S, Valley S, Kuhn L, et al. Inappropriate testing for urinary tract infection in hospitalized patients: an
opportunity for improvement. Infection control and hospital epidemiology : the official journal of the Society of
Hospital Epidemiologists of America. Nov 2013;34(11):1204-1207.
48. 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 for Microbiology and Infectious Diseases. Clinical infectious diseases :
an official publication of the Infectious Diseases Society of America. Mar 1 2011;52(5):e103-120.
49. Safdar N, Slattery WR, Knasinski V, et al. Predictors and outcomes of candiduria in renal transplant
recipients. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.
May 15 2005;40(10):1413-1421.
50. Nicolle LE. Asymptomatic bacteriuria: when to screen and when to treat. Infectious disease clinics of North
America. Jun 2003;17(2):367-394.
51. Nicolle LE. Asymptomatic bacteriuria in the elderly. Infectious disease clinics of North America. Sep
1997;11(3):647-662.
52. Warren JW, Tenney JH, Hoopes JM, Muncie HL, Anthony WC. A prospective microbiologic study of
bacteriuria in patients with chronic indwelling urethral catheters. The Journal of infectious diseases. Dec
1982;146(6):719-723.
53. Zhanel GG, Harding GK, Nicolle LE. Asymptomatic bacteriuria in patients with diabetes mellitus. Reviews of
infectious diseases. Jan-Feb 1991;13(1):150-154.
54. Smaill F. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev.
2001(2):CD000490.
55. Larimore WL, Petrie KA. Drug use during pregnancy and lactation. Prim. Care. Mar 2000;27(1):35-53.
56. Brumfitt W, Pursell R. Trimethoprim-sulfamethoxazole in the treatment of bacteriuria in women. The Journal
of infectious diseases. Nov 1973;128:Suppl:657-665 p.
57. Information P. Macrobid(R), nitrofurantoin monohydrate/macrocrystals. Proctor & Gamble Pharmaceuticals,.
2002;Cincinnati, OH.
58. Boerema JB, Willems FT. Fosfomycin trometamol in a single dose versus norfloxacin for seven days in the
treatment of uncomplicated urinary infections in general practice. Infection. 1990;18 Suppl 2:S80-88.
59. Neu HC. Fosfomycin trometamol versus amoxycillin--single-dose multicenter study of urinary tract infections.
Chemotherapy. 1990;36 Suppl 1:19-23.
60. Villar J, Lydon-Rochelle MT, Gulmezoglu AM, Roganti A. Duration of treatment for asymptomatic bacteriuria
during pregnancy. Cochrane Database Syst Rev. 2000(2):CD000491.
61. Paick SH, Park HK, Oh SJ, Kim HH. Characteristics of bacterial colonization and urinary tract infection after
indwelling of double-J ureteral stent. Urology. Aug 2003;62(2):214-217.
62. Meiland R, Stolk RP, Geerlings SE, et al. Association between Escherichia coli bacteriuria and renal function
in women: long-term follow-up. Archives of internal medicine. Feb 12 2007;167(3):253-257.
63. Turney JH, Marshall DH, Brownjohn AM, Ellis CM, Parsons FM. The evolution of acute renal failure, 1956-
1988. Q. J. Med. Jan 1990;74(273):83-104.
64. Saitoh H, Nakamura K, Hida M, Satoh T. Urinary tract infection in oliguric patients with chronic renal failure.
The Journal of urology. Jun 1985;133(6):990-993.
65. Kamenski G, Wagner G, Zehetmayer S, Fink W, Spiegel W, Hoffmann K. Antibacterial resistances in
uncomplicated urinary tract infections in women: ECO.SENS II data from primary health care in Austria.
BMC infectious diseases. Sep 18 2012;12(1):222.
66. Neuner EA, Sekeres J, Hall GS, van Duin D. Experience with Fosfomycin for the Treatment of Urinary Tract
Infections due to Multi-Drug Resistant Organisms. Antimicrobial agents and chemotherapy. Aug 27 2012.
67. Conklin JD. The pharmacokinetics of nitrofurantoin and its related bioavailability. Antibiot. Chemother.
1978;25:233-252.
68. Johnson L, Sabel A, Burman WJ, et al. Emergence of fluoroquinolone resistance in outpatient urinary
Escherichia coli isolates. The American journal of medicine. Oct 2008;121(10):876-884.
69. Pharmaceuticals BH. Product Information: Avelox oral tablet, injection. Wayne, NJ: Bayer HealthCare
Pharmaceuticals;2008.
70. Kavatha D, Giamarellou H, Alexiou Z, et al. Cefpodoxime-proxetil versus trimethoprim-sulfamethoxazole for
short-term therapy of uncomplicated acute cystitis in women. Antimicrobial agents and chemotherapy. Mar
2003;47(3):897-900.
71. Fosfomycin. Lexicomp Online® , Pediatric & Neonatal Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; June
2, 2015.
72. Falagas ME, Giannopoulou KP, Kokolakis GN, Rafailidis PI. Fosfomycin: use beyond urinary tract and
gastrointestinal infections. Clinical infectious diseases : an official publication of the Infectious Diseases
Society of America. Apr 1 2008;46(7):1069-1077.
73. Patel SS, Balfour JA, Bryson HM. Fosfomycin tromethamine. A review of its antibacterial activity,
pharmacokinetic properties and therapeutic efficacy as a single-dose oral treatment for acute uncomplicated
lower urinary tract infections. Drugs. Apr 1997;53(4):637-656.
74. Rubenstein JN, Schaeffer AJ. Managing complicated urinary tract infections: the urologic view. Infectious
disease clinics of North America. Jun 2003;17(2):333-351.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

32
75. Naber KG, Bergman B, Bishop MC, et al. EAU guidelines for the management of urinary and male genital
tract infections. Urinary Tract Infection (UTI) Working Group of the Health Care Office (HCO) of the
European Association of Urology (EAU). European urology. Nov 2001;40(5):576-588.
76. Sanchez M, Collvinent B, Miro O, et al. Short-term effectiveness of ceftriaxone single dose in the initial
treatment of acute uncomplicated pyelonephritis in women. A randomised controlled trial. Emergency
medicine journal : EMJ. Jan 2002;19(1):19-22.
77. Gilbert DN. Once-daily aminoglycoside therapy. Antimicrobial agents and chemotherapy. Mar
1991;35(3):399-405.
78. Bendush CL, Weber R. Tobramycin sulfate: a summary of worldwide experience from clinical trials. The
Journal of infectious diseases. Aug 1976;134 Suppl:S219-234.
79. Talan DA, Stamm WE, Hooton TM, et al. Comparison of ciprofloxacin (7 days) and trimethoprim-
sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis pyelonephritis in women: a randomized
trial. JAMA : the journal of the American Medical Association. Mar 22-29 2000;283(12):1583-1590.
80. Stass H, Dalhoff A, Kubitza D, Schuhly U. Pharmacokinetics, safety, and tolerability of ascending single
doses of moxifloxacin, a new 8-methoxy quinolone, administered to healthy subjects. Antimicrobial agents
and chemotherapy. Aug 1998;42(8):2060-2065.
81. Sandberg T, Skoog G, Hermansson AB, et al. Ciprofloxacin for 7 days versus 14 days in women with acute
pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet.
Aug 4 2012;380(9840):484-490.
82. Nicolle LE. Minimum antimicrobial treatment for acute pyelonephritis. Lancet. Aug 4 2012;380(9840):452-
453.
83. Niel-Weise BS, van den Broek PJ. Urinary catheter policies for short-term bladder drainage in adults.
Cochrane Database Syst Rev. 2005(3):CD004203.
84. Niel-Weise BS, van den Broek PJ. Urinary catheter policies for long-term bladder drainage. Cochrane
Database Syst Rev. 2005(1):CD004201.
85. Garibaldi RA, Burke JP, Dickman ML, Smith CB. Factors predisposing to bacteriuria during indwelling
urethral catheterization. The New England journal of medicine. Aug 1 1974;291(5):215-219.
86. Niel-Weise BS, van den Broek PJ. Antibiotic policies for short-term catheter bladder drainage in adults.
Cochrane Database Syst Rev. 2005(3):CD005428.
87. Marschall J, Carpenter CR, Fowler S, Trautner BW. Antibiotic prophylaxis for urinary tract infections after
removal of urinary catheter: meta-analysis. BMJ. 2013;346:f3147.
88. Richter S, Lang R, Zur F, Nissenkorn I. Infected urine as a risk factor for postprostatectomy wound infection.
Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of
America. Mar 1991;12(3):147-149.
89. Rao PN, Dube DA, Weightman NC, Oppenheim BA, Morris J. Prediction of septicemia following
endourological manipulation for stones in the upper urinary tract. The Journal of urology. Oct
1991;146(4):955-960.
90. Davies AJ, Desai HN, Turton S, Dyas A. Does instillation of chlorhexidine into the bladder of catheterized
geriatric patients help reduce bacteriuria? The Journal of hospital infection. Jan 1987;9(1):72-75.
91. Waites KB, Canupp KC, Roper JF, Camp SM, Chen Y. Evaluation of 3 methods of bladder irrigation to treat
bacteriuria in persons with neurogenic bladder. J. Spinal Cord Med. 2006;29(3):217-226.
92. Ball AJ, Carr TW, Gillespie WA, Kelly M, Simpson RA, Smith PJ. Bladder irrigation with chlorhexidine for the
prevention of urinary infection after transurethral operations: a prospective controlled study. The Journal of
urology. Sep 1987;138(3):491-494.
93. Richter S, Kotliroff O, Nissenkorn I. Single preoperative bladder instillation of povidone-iodine for the
prevention of postprostatectomy bacteriuria and wound infection. Infection control and hospital epidemiology
: the official journal of the Society of Hospital Epidemiologists of America. Oct 1991;12(10):579-582.
94. Foon R, Toozs-Hobson P, Latthe P. Prophylactic antibiotics to reduce the risk of urinary tract infections after
urodynamic studies. Cochrane Database Syst Rev. 2012;10:CD008224.
95. Musher DM, McKenzie SO. Infections due to Staphylococcus aureus. Medicine (Baltimore). Sep
1977;56(5):383-409.
96. Lee BK, Crossley K, Gerding DN. The association between Staphylococcus aureus bacteremia and
bacteriuria. The American journal of medicine. Aug 1978;65(2):303-306.
97. Muder RR, Brennen C, Rihs JD, et al. Isolation of Staphylococcus aureus from the urinary tract: association
of isolation with symptomatic urinary tract infection and subsequent staphylococcal bacteremia. Clinical
infectious diseases : an official publication of the Infectious Diseases Society of America. Jan 1
2006;42(1):46-50.
98. Wong AH, Wenzel RP, Edmond MB. Epidemiology of bacteriuria caused by vancomycin-resistant
enterococci--a retrospective study. American journal of infection control. Aug 2000;28(4):277-281.
99. Williamson JC, Craft DW, Butts JD, Raasch RH. In vitro assessment of urinary isolates of ampicillin-resistant
enterococci. The Annals of pharmacotherapy. Feb 2002;36(2):246-250.
100. Cole KA, Davis SL, Samuel LP, Perri M, Zervos M, Kenney RM. Aminopenicillins for Vancomycin-Resistant
Enterococcal (VRE) Urinary Tract Infection (UTI): Does MIC Matter? Poster session presented at: 54th
Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC); 2014 Sep 5-9; Washington,
D.C.
101. Griffith DP, Musher DM, Itin C. Urease. The primary cause of infection-induced urinary stones. Invest. Urol.
Mar 1976;13(5):346-350.
102. Ronald A. The etiology of urinary tract infection: traditional and emerging pathogens. The American journal
of medicine. Jul 8 2002;113 Suppl 1A:14S-19S.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

33
103. Sobel JD, Kaye D. Urinary Tract Infections. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and
Bennett's principles and practice of infectious diseases. Vol 1. 7th ed ed. Philadelphia, PA: Churchill
Livingstone Elsevier; 2011:957-985.
104. Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis:
2009 update by the Infectious Diseases Society of America. Clinical infectious diseases : an official
publication of the Infectious Diseases Society of America. Mar 1 2009;48(5):503-535.
105. Chitale SV, Shaida N, Burtt G, Burgess N. Endoscopic management of renal candidiasis. Journal of
endourology / Endourological Society. Nov 2004;18(9):865-866.
106. Babu R, Hutton KA. Renal fungal balls and pelvi-ureteric junction obstruction in a very low birth weight
infant: treatment with streptokinase. Pediatr. Surg. Int. Oct 2004;20(10):804-805.
107. Shih MC, Leung DA, Roth JA, Hagspiel KD. Percutaneous extraction of bilateral renal mycetomas in
premature infant using mechanical thrombectomy device. Urology. Jun 2005;65(6):1226.
108. Boedeker KS, Kilzer WJ. Fluconazole dose recommendation in urinary tract infection. The Annals of
pharmacotherapy. Mar 2001;35(3):369-372.
109. Potasman I, Castin A, Moskovitz B, Srugo I, Nativ O. Oral fluconazole for Candida urinary tract infection.
Urologia internationalis. 1997;59(4):252-256.
110. Fisher JF, Sobel JD, Kauffman CA, Newman CA. Candida urinary tract infections--treatment. Clinical
infectious diseases : an official publication of the Infectious Diseases Society of America. May 2011;52
Suppl 6:S457-466.
111. Diasio RB, Lakings DE, Bennett JE. Evidence for conversion of 5-fluorocytosine to 5-fluorouracil in humans:
possible factor in 5-fluorocytosine clinical toxicity. Antimicrobial agents and chemotherapy. Dec
1978;14(6):903-908.
112. Wise GJ, Wainstein S, Goldberg P, Kozinn PJ. Flucytosine in urinary candida infections. Urology. Jun
1974;3(6):708-711.
113. Nesbit SA, Katz LE, McClain BW, Murphy DP. Comparison of two concentrations of amphotericin B bladder
irrigation in the treatment of funguria in patients with indwelling urinary catheters. American journal of health-
system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. May 1
1999;56(9):872-875.
114. Agustin J, Lacson S, Raffalli J, Aguero-Rosenfeld ME, Wormser GP. Failure of a lipid amphotericin B
preparation to eradicate candiduria: preliminary findings based on three cases. Clinical infectious diseases :
an official publication of the Infectious Diseases Society of America. Sep 1999;29(3):686-687.
115. Janknegt R, de Marie S, Bakker-Woudenberg IA, Crommelin DJ. Liposomal and lipid formulations of
amphotericin B. Clinical pharmacokinetics. Clin. Pharmacokinet. Oct 1992;23(4):279-291.
116. Lopez-Medrano F, Garcia-Bravo M, Morales JM, et al. Urinary tract infection due to Corynebacterium
urealyticum in kidney transplant recipients: an underdiagnosed etiology for obstructive uropathy and graft
dysfunction-results of a prospective cohort study. Clinical infectious diseases : an official publication of the
Infectious Diseases Society of America. Mar 15 2008;46(6):825-830.
117. Soriano F, Aguado JM, Ponte C, Fernandez-Roblas R, Rodriguez-Tudela JL. Urinary tract infection caused
by Corynebacterium group D2: report of 82 cases and review. Reviews of infectious diseases. Nov-Dec
1990;12(6):1019-1034.
118. Lee BB, Haran MJ, Hunt LM, et al. Spinal-injured neuropathic bladder antisepsis (SINBA) trial. Spinal Cord.
Aug 2007;45(8):542-550.
119. Barbosa-Cesnik C, Brown MB, Buxton M, Zhang L, DeBusscher J, Foxman B. Cranberry juice fails to
prevent recurrent urinary tract infection: results from a randomized placebo-controlled trial. Clinical infectious
diseases : an official publication of the Infectious Diseases Society of America. Jan 1 2011;52(1):23-30.
120. Lee B, Bhuta T, Craig J, Simpson J. Methenamine hippurate for preventing urinary tract infections.
Cochrane Database Syst Rev. 2002(1):CD003265.
121. Strom JG, Jr., Jun HW. Effect of urine pH and ascorbic acid on the rate of conversion of methenamine to
formaldehyde. Biopharm. Drug Dispos. Jan 1993;14(1):61-69.
122. Ochoa-Brust GJ, Fernandez AR, Villanueva-Ruiz GJ, Velasco R, Trujillo-Hernandez B, Vasquez C. Daily
intake of 100 mg ascorbic acid as urinary tract infection prophylactic agent during pregnancy. Acta Obstet
Gynecol Scand. 2007;86(7):783-787.
123. Raz R, Gennesin Y, Wasser J, et al. Recurrent urinary tract infections in postmenopausal women. Clinical
infectious diseases : an official publication of the Infectious Diseases Society of America. Jan
2000;30(1):152-156.
124. Eriksen B. A randomized, open, parallel-group study on the preventive effect of an estradiol-releasing
vaginal ring (Estring) on recurrent urinary tract infections in postmenopausal women. Am. J. Obstet.
Gynecol. May 1999;180(5):1072-1079.
125. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary
tract infections. The New England journal of medicine. Sep 9 1993;329(11):753-756.
126. Bergsten G, Samuelsson M, Wullt B, Leijonhufvud I, Fischer H, Svanborg C. PapG-dependent adherence
breaks mucosal inertia and triggers the innate host response. The Journal of infectious diseases. May 1
2004;189(9):1734-1742.
127. Wagenlehner FM, Krcmery S, Held C, et al. Epidemiological analysis of the spread of pathogens from a
urological ward using genotypic, phenotypic and clinical parameters. International journal of antimicrobial
agents. Jun 2002;19(6):583-591.
128. Abad CL, Safdar N. The role of lactobacillus probiotics in the treatment or prevention of urogenital infections-
-a systematic review. J. Chemother. Jun 2009;21(3):243-252.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

34
129. Wolf JS, Jr., Bennett CJ, Dmochowski RR, Hollenbeck BK, Pearle MS, Schaeffer AJ. Urologic surgery
antimicrobial prophylaxis: American Urological Association Education and Research, Inc; 2007.
130. Tambyah PA, Maki DG. The relationship between pyuria and infection in patients with indwelling urinary
catheters: a prospective study of 761 patients. Archives of internal medicine. Mar 13 2000;160(5):673-677.
131. Sundvall PD, Gunnarsson RK. Evaluation of dipstick analysis among elderly residents to detect bacteriuria:
a cross-sectional study in 32 nursing homes. BMC geriatrics. 2009;9:32.
132. Cai T, Mazzoli S, Mondaini N, et al. The role of asymptomatic bacteriuria in young women with recurrent
urinary tract infections: to treat or not to treat? Clinical infectious diseases : an official publication of the
Infectious Diseases Society of America. Sep 2012;55(6):771-777.
133. Beveridge LA, Davey PG, Phillips G, McMurdo ME. Optimal management of urinary tract infections in older
people. Clinical interventions in aging. 2011;6:173-180.
134. Nicolle LE. Asymptomatic bacteriuria in institutionalized elderly people: evidence and practice. CMAJ. Aug 8
2000;163(3):285-286.
135. Drinka PJ, Crnich CJ. Diagnostic accuracy of criteria for urinary tract infection in a cohort of nursing home
residents. Journal of the American Geriatrics Society. Feb 2008;56(2):376-377; author reply 378.
136. Kauffman CA, Vazquez JA, Sobel JD, et al. Prospective multicenter surveillance study of funguria in
hospitalized patients. The National Institute for Allergy and Infectious Diseases (NIAID) Mycoses Study
Group. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Jan
2000;30(1):14-18.





Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

35
Appendix 1. Diagnosis of Urinary Tract Infection – Top Ten Myths
Lucas Schulz, PharmD, BCPS; Robert Hoffman, MD; Jeffrey Pothof, MD; Barry Fox, MD

For further reading consider:
1. Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship
Approach for Urinary Catheter-Associated Asymptomatic Bacteriuria. JAMA Intern Med.
2015;175(7): 1120-1127.
2. Kalra R, Kraemer RR. Urinary catheterization -- when good intentions go awry: a teachable
moment. JAMA Intern Med. 2014;174(10): 1547-1548.

The diagnosis of UTI is not a laboratory defined diagnosis. The diagnosis should be based on
clinical symptoms combined with supportive laboratory information, if obtained.

Myth 1: The urine is cloudy and smells bad. My patient has a UTI.
Truth 1: Urine color and clarity or odor should not be used alone to diagnose or start antibiotic therapy in
any patient population.

a. Visual inspection of urine clarity is not helpful in diagnosing UTI in women.37
a. 100 female patients at a university hospital had their urine tested by reading newsprint
through the sample. The sensitivity, specificity, and positive and negative predictive
values were 13.3%, 96.5%, 40.0%, and 86.3% respectively.
b. Foul smelling urine is an unreliable indicator of infection in catheterized patients, and usually
dependent on a patients hydration status and concentration of urea in the urine.1,38

Myth 2: The urine has bacteria present. My patient has a UTI. Also see Myth 8.
Truth 2: The presence of bacteria in the urine on microscopic examination without UTI symptoms is NOT
recommended for the diagnosis of UTI due to the possibility of contamination and asymptomatic
bacteriuria42

a. UTI is not a laboratory defined diagnosis. Diagnosis should be based on clinical symptoms. The
bacterial thresholds (below) should usually be present in patients with a UTI; however, the
absence of bacteria does not rule out UTI in patients with clinical symptoms.
b. In patients without an indwelling catheter the following cutoffs should define significant
bacteriuria6
i. ≥ 105 CFU/mL of ≤ 2 species of microorganisms in voided culture
ii. ≥ 102 CFU/mL of any number of microorganisms in a straight cath culture
c. In patients with an indwelling catheter, ≥103 CFU/mL of any organism(s) should define significant
bacteriuria6 since this is predictive of higher colony counts of 10 to the fifth within 48 hours130

Myth 3: My patient’s urine sample has >5 squamous epithelial cells per low powered field and the
culture is positive. Because the culture is positive, I can disregard the epithelial cell count and
treat the UTI.
Truth 3: A good specimen has less than 5 epithelial cells per low power field on UA. Poor specimens
should be considered for recollection or straight catheterization should be performed.

Myth 4: The urine has positive leukocyte esterase. My patient has a UTI and needs antibiotics.
Truth 4: Urine leukocyte esterase should not be used alone to diagnosis or start antimicrobial therapy in
any patient population.

a. A dipstick leukocyte esterase test has high sensitivity and specificity for the presence of
quantitative pyuria, 80-90% and 95-98%, respectively; however a positive leukocyte esterase
alone is NOT recommended for diagnosis of UTI.39,40Pyuria or bacteriuria alone is not an
indication for antimicrobial therapy
b. On rare occasions, a negative leukocyte esterase in the presence of UTI symptoms may still
prompt a urine culture if clinically suspected39,40 but especially prompt a search for urethritis,
vaginitis, or sexually transmitted infection.

Myth 5: My patient has pyuria. They must have a UTI.
Truth 5: Quantitative urine WBC should not be used alone to diagnosis or start antimicrobial therapy in
any patient population

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

36
a. In neutropenic or leukopenic patients, the WBC count may be artificially low and reflex culture
may not occur. The microbiology lab should be contacted and an order for urine culture ordered if
urinary symptoms are present and urinary source of infection is suspected.
b. Borderline WBC counts of 6-10 may reflect the patient’s state of hydration. Patients with oliguria
or anuria (dialysis) usually have some degree of pyuria.
c. Non-infectious conditions, such as sexually transmitted infections or non-infectious cystitis may
give pyuria.

Myth 6: The urine has nitrates present. My patient has a UTI.
Truth 6: Urine nitrates should not be used alone to diagnosis or start antimicrobial therapy in any patient
population.

a. Urine nitrate has a high true-positive rate for bacteriuria, but bacteriuria, as noted above in Myth
2, does not define a clinically significant UTI Diagnosis of UTI should be considered in a patient
with elevated urine nitrate in the presence of clinical signs and symptoms of UTI.39,42
b. A negative leukocyte esterase AND a negative urine nitrate largely rule out infection in pregnant
women, elderly patients, family medicine, and urology patients.41 Alternative diagnosis should be
thoroughly investigated in this scenario.
c. In an analysis of the negative predictive value for pathogenic bacteria using the combined nitrite
and leukocyte esterase dipstick analysis, the combination of a negative leukocyte esterase and
negative nitrite test demonstrated an NPV of 88% (CI: 84%-92%).
d. If both leukocyte esterase AND nitrite analyses are positive, the sensitivity for bacteriuria was
48% (CI: 41%-55%), and specificity was 93% (CI: 90%-95%).131 See Myth 2

Myth 7: All findings of bacteria in a catheterized urine sample should be diagnosed as a UTI.
Truth 7: Virtually 100% of patients with an indwelling Foley catheter are colonized within 2 weeks of
placement with 2-5 organisms. Colony counts of a catheter may define bacteriuria but must be taken in a
clinical context for making a diagnosis of UTI.

a. 98% of chronically catheterized patients had bacteriuria and 77% were polymicrobial. The mean
interval between new episodes of bacteriuria was 1.8 weeks.52
b. Bacteriuria and pyuria in chronically catheterized patients should only be treated in the presence
of signs and symptoms of infection (e.g. fever, leukocytosis, suprapubic pain and tenderness.
Dysuria is obviously unassessable). Pyuria or bacteriuria alone is not an indication for
antimicrobial therapy.
c. Patients with intermittent or condom catheters are at lower risk for UTI and should be considered
in the same risk category as those with no indwelling catheter.46
d. While antibiotics may delay the onset of bacteriuria in catheterized patients, this strategy
ultimately selects for resistant microorganisms. Prophylactic anti-infectives are not recommended
for patients with chronic catheters, but may be considered for short-term use by urology
specialists

Myth 8: Bacteriuria results in urinary tract infections and should be treated with antibiotics.
Truth 8: Bacteriuria does NOT establish a diagnosis of a UTI and does NOT necessarily require initiation
of antimicrobial therapy for asymptomatic bacteriuria.

a. The prevalence of bacteriuria in elderly institutionalized patient without indwelling catheters varies
from 25-50% for women and 15-49% for men and increases with age.10 Bacteriuria and pyuria
in the elderly is, to a large degree, an expected finding.
b. Symptomatic UTI is substantially less common than asymptomatic bacteriuria.
c. Asymptomatic bacteriuria has not been associated with long-term negative outcomes, such as
pyelonephritis, sepsis, renal failure or hypertension.51
d. The overuse of antibiotics leads to antibiotic resistance and potential side effects.28,29,31
e. Pyuria, leukocyte esterase, or nitrate, individually, accompanying asymptomatic bacteriuria are
NOT necessarily an indication for antimicrobial treatment in the general population.1 Some
exceptions include: pregnancy33 and patients with urinary tract stenting61
f. Recent evidence suggests that in younger women with true recurrent UTI, that bacteriuria may be
“protective” for future UTI with more pathogenic organisms.132

Myth 9: Falls and acute altered mental status changes in the elderly patient are usually caused by
UTI.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

37
Truth 9: Altered mental status and falls in the elderly are caused by many factors. Other signs and
symptoms of UTI, especially dysuria (when able to assess) should be present to make the diagnosis of
UTI in non-catheterized patients. Symptoms of active infection in a catheterized patient are obviously
more difficult to assess.45

a. Elderly patients with acute mental status changes accompanied by bacteriuria and pyuria without
clinical instability or other signs or symptoms of UTI can reasonably be observed for resolution of
confusion for 24-48 hours without antibiotics133,134, while searching for other causes of confusion.
1. In all elderly patients, acute mental status change and functional decline are non-
specific clinical manifestations of several circumstances, including, but not limited to
dehydration, hypoxia, and poly-pharmacy adverse reactions. Diagnosis of UTI
should be correlated with others signs of systemic inflammation,
b. In the non-catheterized patient, acute changes in mental status was associated with bacteriuria
plus pyuria in patients with clinically suspected UTI.7
1. However, these two findings are also frequently demonstrated in elderly patients with
asymptomatic bacteriuria and attribution of altered mental status to bacteriuria can
result in failure to identify the true cause. 25,26,135 Falls without localizing urinary
symptoms were not associated with bacteriuria or pyuria.8,9
c. Elderly patients, especially those with dementia or indwelling Foley catheters, have high rates of
bacteriuria and may NOT have UTI symptoms10. Diagnosis of infection/sepsis of a urinary source
with simple bacteriuria is not recommended unless other infectious sources have been excluded
and patients meet urine criteria suspicious for infection. Diagnosis of UTI in the catheterized
patient should always be a diagnosis of exclusion by investigating other causes for altered mental
status in the absence of localized urinary tract findings.6

Myth 10: The presence of yeast or candida in the urine, especially in patients with indwelling
urinary catheters, indicates a candida UTI and needs to be treated.
a. The occurrence of candiduria in the catheterized patient is common, especially in the ICU and
most often reflects colonization or asymptomatic infection. Treatment of candida in the urine
should only occur in rare situations, such as clear signs and symptoms of infection and no
alternative source of infection
b. Treatment of asymptomatic candiduria in non-neutropenic catheterized patients has usually not
been shown to be valuable 136
c. “Treatment” of candiduria should first include replacement/removal of urinary tract instruments.
d. Except in selected highest risk transplant recipients, or immuno-compromised hosts who are
receiving steroids, or clinical scenarios for patients at high risk of systemic candidiasis, candiduria
has a low incidence of systemic complications , and conservative observation is usually indicated.
e. Isolation of candida in the urine of non- catheterized patients should second raise concerns about
vaginal or external contamination. If a reliable specimen is repeatedly obtained with yeast, and
the patient is symptomatic, consideration of anti-fungal therapy may be warranted.

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

38
References for Appendix 1. Diagnosis of Urinary Tract Infection – Top Ten Myths
1. Foley A, French L. Urine clarity inaccurate to rule out urinary tract infection in women. Journal of the
American Board of Family Medicine : JABFM. Jul-Aug 2011;24(4):474-475.
2. Nicolle LE. The chronic indwelling catheter and urinary infection in long-term-care facility residents.
Infection control and hospital epidemiology : the official journal of the Society of Hospital
Epidemiologists of America. May 2001;22(5):316-321.
3. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of
America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clinical
infectious diseases : an official publication of the Infectious Diseases Society of America. Mar 1
2005;40(5):643-654.
4. Van Nostrand JD, Junkins AD, Bartholdi RK. Poor predictive ability of urinalysis and microscopic
examination to detect urinary tract infection. American journal of clinical pathology. May
2000;113(5):709-713.
5. Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities:
revisiting the McGeer criteria. Infection control and hospital epidemiology : the official journal of the
Society of Hospital Epidemiologists of America. Oct 2012;33(10):965-977.
6. Tambyah PA, Maki DG. The relationship between pyuria and infection in patients with indwelling
urinary catheters: a prospective study of 761 patients. Archives of internal medicine. Mar 13
2000;160(5):673-677.
7. Pappas PG. Laboratory in the diagnosis and management of urinary tract infections. The Medical
clinics of North America. Mar 1991;75(2):313-325.
8. Bent S, Saint S. The optimal use of diagnostic testing in women with acute uncomplicated cystitis.
The American journal of medicine. Jul 8 2002;113 Suppl 1A:20S-28S.
9. Deville WL, Yzermans JC, van Duijn NP, Bezemer PD, van der Windt DA, Bouter LM. The urine
dipstick test useful to rule out infections. A meta-analysis of the accuracy. BMC urology. Jun 2
2004;4:4.
10. Sundvall PD, Gunnarsson RK. Evaluation of dipstick analysis among elderly residents to detect
bacteriuria: a cross-sectional study in 32 nursing homes. BMC geriatrics. 2009;9:32.
11. Warren JW, Tenney JH, Hoopes JM, Muncie HL, Anthony WC. A prospective microbiologic study of
bacteriuria in patients with chronic indwelling urethral catheters. The Journal of infectious diseases.
Dec 1982;146(6):719-723.
12. Loeb M, Bentley DW, Bradley S, et al. Development of minimum criteria for the initiation of antibiotics
in residents of long-term-care facilities: results of a consensus conference. Infection control and
hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America. Feb
2001;22(2):120-124.
13. Nicolle LE. Urinary tract infections in long-term-care facilities. Infection control and hospital
epidemiology : the official journal of the Society of Hospital Epidemiologists of America. Mar
2001;22(3):167-175.
14. Nicolle LE. Asymptomatic bacteriuria in the elderly. Infectious disease clinics of North America. Sep
1997;11(3):647-662.
15. Frank U, Kleissle EM, Daschner FD, et al. Multicentre study of antimicrobial resistance and antibiotic
consumption among 6,780 patients with bloodstream infections. European journal of clinical
microbiology & infectious diseases : official publication of the European Society of Clinical
Microbiology. Dec 2006;25(12):815-817.
16. Tacconelli E, De Angelis G, Cataldo MA, Pozzi E, Cauda R. Does antibiotic exposure increase the
risk of methicillin-resistant Staphylococcus aureus (MRSA) isolation? A systematic review and meta-
analysis. The Journal of antimicrobial chemotherapy. Jan 2008;61(1):26-38.
17. Burke JP. Antibiotic resistance--squeezing the balloon? JAMA : the journal of the American Medical
Association. Oct 14 1998;280(14):1270-1271.
18. ACOG Practice Bulletin No. 91: Treatment of urinary tract infections in nonpregnant women.
Obstetrics and gynecology. Mar 2008;111(3):785-794.
19. Paick SH, Park HK, Oh SJ, Kim HH. Characteristics of bacterial colonization and urinary tract
infection after indwelling of double-J ureteral stent. Urology. Aug 2003;62(2):214-217.
20. Cai T, Mazzoli S, Mondaini N, et al. The role of asymptomatic bacteriuria in young women with
recurrent urinary tract infections: to treat or not to treat? Clinical infectious diseases : an official
publication of the Infectious Diseases Society of America. Sep 2012;55(6):771-777.
21. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a
prospective study of 1,497 catheterized patients. Archives of internal medicine. Mar 13
2000;160(5):678-682.
22. Beveridge LA, Davey PG, Phillips G, McMurdo ME. Optimal management of urinary tract infections in
older people. Clinical interventions in aging. 2011;6:173-180.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

39
23. Nicolle LE. Asymptomatic bacteriuria in institutionalized elderly people: evidence and practice. CMAJ.
Aug 8 2000;163(3):285-286.
24. Juthani-Mehta M, Quagliarello V, Perrelli E, Towle V, Van Ness PH, Tinetti M. Clinical features to
identify urinary tract infection in nursing home residents: a cohort study. Journal of the American
Geriatrics Society. Jun 2009;57(6):963-970.
25. Drinka PJ, Crnich CJ. Diagnostic accuracy of criteria for urinary tract infection in a cohort of nursing
home residents. Journal of the American Geriatrics Society. Feb 2008;56(2):376-377; author reply
378.
26. Nicolle LE. Urinary tract infections in the elderly. Clin. Geriatr. Med. Aug 2009;25(3):423-436.
27. Nicolle LE. Symptomatic urinary tract infection in nursing home residents. Journal of the American
Geriatrics Society. Jun 2009;57(6):1113-1114.
28. Kauffman CA, Vazquez JA, Sobel JD, et al. Prospective multicenter surveillance study of funguria in
hospitalized patients. The National Institute for Allergy and Infectious Diseases (NIAID) Mycoses
Study Group. Clinical infectious diseases : an official publication of the Infectious Diseases Society of
America. Jan 2000;30(1):14-18.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org