Page updated Winter 2021.
Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable resources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original resources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.
Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable resources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original resources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.
Acute Uncomplicated
Cystitis Nitrofurantoin monohydrate 100 mg twice daily for 5 days It is an appropriate choice. Its efficacy is comparable to 3 days of trimethoprim-sulfamethoxazole. There is minimal resistance and propensity for collateral damage. Trimethoprim-sulfamethoxazole 160/800 mg twice-daily for 3 days. It is an appropriate choice. Fluoroquinolones 3-day regimens Options: ofloxacin, ciprofloxacin, and levofloxacin Highly efficacious Should be considered an alternative antimicrobials for acute cystitis, when other options don't work. Fosfomycin 3 g in a single dose It has inferior efficacy. B-Lactam agents 3–7-day. Choices are: amoxicillin-clavulanate,
cefdinir, cefaclor, and cefpodoxime-proxetil Inferior efficacy More adverse effects Should be used with caution for
uncomplicated cystitis. Emphysematous Cystitis Antibiotics: Broad gram-negative coverage- IV Enterococcal coverage if Gram stain shows gram-positive cocci Bladder drainage Treatment of comorbid conditions like diabetes Surgery: Rarely needed. Case reports have described debridement, partial cystectomy, and total cystectomy. Asymptomatic Bacteriuria Do not screen or treat: Pediatric patients Women without risk factors Post-menopausal women Patients with well-regulated diabetes mellitus Elderly institutionalised patients Patients with dysfunctional and/or reconstructed lower urinary tracts Patients with renal transplants Prior to arthoplasty surgeries Patients with recurrent urinary tract infections Pyuria accompanying asymptomatic bacteriuria: Should not be treated with antimicrobial therapy. Screen and treat Prior to urological procedures breaching the mucosa Pregnant women Renal transplant patients If >1 month after renal transplant: no treatment. Nonrenal solid organ transplant: no treatment. High-risk neutropenia (absolute neutrophil count <100 cells/mm3, ≥7 days duration following chemotherapy): No recommendation for or against treatment Asymptomatic Bacteriuria and Cystitis in Pregnancy Cephalexin 500 mg four times daily Nitrofurantoin 100 mg four times daily No G6PD deficiency | Acute Pyelonephritis- Not Requiring Hospitalization Oral ciprofloxacin 500 mg twice daily for 7 days Intravenous ciprofloxacin 400-mg, one initial dose May or may not be given. Acute Pyelonephritis- Requiring Hospitalization Intravenous Antibiotics for 10-14 days. Choices are: Fluoroquinolone- Not a good choice for complicated PN. Extended-spectrum cephalosporin Extended-spectrum penicillin Carbapenem In case of gram-positive cocci in initial Gram stain enterococcal coverage should be included. Urosepsis Diagnosis: Urine culture Two sets of blood culture Other related tests to rule out other sources of sepsis Treatment Resuscitation Antibiotics- IV broad spectrum antimicrobials. Refer to common medication page. Removal of foreign bodies Decompression of obstruction Drainage of abscesses Acute Pyelonephritis in Pregnancy Hospitalize IV fluids Cooling blanket Acetaminophen IV antibiotics: Second or third generation cephalosporins Carbapenems: in severe multidrug-resistant infection. Renal ultrasound: if no improvement in 72 hours Asymptomatic Candiduria Elimination of predisposing factors Indwelling bladder catheters Systemic antifungal treatment Treatment with antifungal agents is NOT recommended. Treat only if: Neutropenic- Candidemia Protocol Very low-birth-weight infants (<1500 g)- Candidemia Protocol Before urologic manipulation- Fluconazole For doses refer to common medication page. Symptomatic Candida Cystitis Antifungal treatment Refer to common medication page. Amphotericin B deoxycholate Irrigation: 50 mg/L sterile water daily for 5 days. Irrigation may be helpful for treatment of cystitis due to fluconazole-resistant species, such as C. glabrata and C. krusei. Symptomatic Ascending Candida Pyelonephritis Antifungal treatment Refer to common medication page. Elimination of urinary tract obstruction Nephrostomy tubes or stents removal or replacement Fungus Balls Surgical intervention Antifungal treatment Amphotericin B deoxycholate Irrigation: Use nephrostomy tubes, if present. 25–50 mg in 200–500 mL sterile water | Infected Hydronephrosis and Pyonephrosis Antimicrobial Therapy Drainage- ureteral catheter or percutaneous nephrostomy tube Emphysematous pyelonephritis Fluid resuscitation Glucose management Electrolyte management Antimicrobial therapy Drainage: Ureteral catheter or percutaneous nephrostomy tube Nephrectomy: Only if there is extensive diffuse gas with renal destruction. Renal Abscess <3 - 5 cm Antibiotics alone Drainage if not responsive to initial antibiotic therapy. Drainage if immunocompromised. > 5 cm Antibiotics Percutaneous drainage They usually require multiple drains, and multiple drain manipulations. Surgical washout and potential nephrectomy might be needed. Perinephric Abscess <3 cm Antibiotics: There should be gram negative and staphylococcal coverage. Percutaneous drainage If not responsive to initial antibiotic therapy. > 3 cm Antibiotics Percutaneous drainage Addressing the underlying problem Xanthogranulomatous Pyelonephritis Antibiotics Nephrectomy: It is usually performed. Partial nephrectomy: If localized. Malacoplakia Antibiotics Recurrent infection should be controlled. Tuberculosis Most common presentations: Hematuria (gross or microscopic), sterile pyuria, storage symptoms, dysuria, fever, and weakness. Other presentations: Pyospermia and hematospermia may occur in men with prostate tuberculosis in endemic areas. If there is history of tuberculosis, investigate for urogenital tuberculosis. Tuberculous epididymitis may occur, typically as chronic epididymitis, in high-risk groups such as men with immunodeficiency and those from endemic areas. It frequently results in a discharging scrotal sinus. Diagnosis: Three sequential early morning urine samples: Cultured for acid-fast bacilli (AFB) and NAAT for M. tuberculosis AFB culture and NAAT test of other secretions Prostate secretion Ejaculate Draining scrotal fistula Fine needle aspiration and biopsy |