Chapter 2.  Empiric Therapy Based on Clinical Syndrome			103
	Empiric Therapy of Genitourinary Tract Infections
Dysuria-Pyuria Syndrome (Acute Urethral Syndrome)
Subset		Usual Pathogens	IV Therapy	PO Therapy
Acute		S.. saprophyticus	Not applicable	Doxycycline 100 mg (PO) q12h × 10 days
urethral		C.. trachomatis		or
syndrome		E.. coli (< 105 cfu/mL)		Quinolone (PO)* × 7 days

*Ciprofloxacin 500 mg q12h or Levofloxacin 500 mg q24h..

Clinical Presentation:  Dysuria, frequency, urgency, lower abdominal discomfort, fevers < 102°F.. Diagnostic Considerations:  Diagnosis by symptoms of cystitis with pyuria and no growth or low concentration of E.. coli (≤ 103 colonies/mL) by urine culture.. Clue to S.. saprophyticus is alkaline urinary pH and RBCs in urine..

Pitfalls:  Resembles “culture negative” cystitis..

Therapeutic Considerations:  S.. saprophyticus is susceptible to most antibiotics used to treat UTIs..

Prognosis:  Excellent..

Cystitis (see Color Atlas for Urine Gram stains)

Subset	Usual Pathogens	Therapy
Bacterial	Enterobacteriaceae	Amoxicillin 500 mg (PO) × q12h × 3 days
	E.. faecalis (VSE)	or
	S.. agalactiae (group B	TMP–SMX 1 SS tablet (PO) × q12h × 3 days
	streptococci)	or
	S.. saprophyticus	Levofloxacin 500 mg (PO) q24h × 3 days
		or
		Nitrofurantoin 100 mg (PO) q12h × 3 days
	MDR GNBs	Fosfomycin 3 gm (PO) q24h × 3 days
Fungal	C.. albicans†	Fluconazole 200 mg (PO) × 1 dose, then 100 mg (PO) q24h
		× 4 days
	Fluconazole-resistant‡	Amphotericin B 0..3 mg/kg (IV) × 1 dose
	Candida isolates or
	fluconazole-refractory
	disease

†C.. albicans cystitis (see p.. 104)

‡Fluconazole-resistant (see p.. 104)

104	A n t i b i o t i c E s s e n t i a l s

Bacterial Cystitis

Clinical Presentation:  Dysuria, frequency, urgency, lower abdominal discomfort, fevers < 102°F..

Diagnostic Considerations:  Pyuria plus bacteriuria..

Pitfalls:  Compromised hosts (chronic steroids, diabetes, SLE, cirrhosis, multiple myeloma) may require 3–5 days of therapy.. A single dose of amoxicillin or TMP–SMX may be sufficient in acute uncomplicated cystitis in normal hosts..

Therapeutic Considerations:  Pyridium 200 mg (PO) q8h after meals × 24–48h is useful to decrease dysuria (inform patients urine will turn orange)..

Prognosis:  Excellent in normal hosts..

Candida Cystitis

Diagnostic Considerations:  Marked pyuria, urine nitrate negative ±RBCs.. Speciate if not C.. albicans.. Pitfalls:  Lack of response suggests renal candidiasis or a “fungus ball” in the renal collecting system.. Therapeutic Considerations:  If fluconazole fails, use amphotericin.. For chronic renal failure/dialysis patients with candiduria, use amphotericin B deoxycholate bladder irrigation (as for catheter-associated candiduria, below).. Removal of devices and correction of anatomic abnormalities are critical to success.. Prognosis:  Patients with impaired host defenses, abnormal collecting systems, cysts, renal disease or stones are prone to recurrent UTIs/urosepsis..

Catheter Associated Bacteriuria (CAB)

	Subset	Usual Pathogens	Therapy
	Catheter	E.. coli	Nitrofurantoin 100 mg (PO) q12h × 3 days
	associated	E.. faecalis (VSE)	or
	bacteriuria		Amoxicillin 500 mg (PO) q12h × 3 days
	(CAB)†*
		E.. faecium (VRE)	Nitrofurantoin 100 mg (PO) q12h × 3 days
			or
			Fosomycin 3 gm (PO) q24h × 3 days††
		MDR Klebsiella††	Nitrofurantoin 100 mg (PO) q12h × 3 days††
		MDR Acinetobacter††	or
		MDR P.. aeruginosa††	Fosomycin 3 gm (PO) q24h × 3 days††
			or
			Meropenem 1 gm (IV) q8h × 3 day††§
			or
			Doripenem 1 gm (IV) q8h × 3 days††§

VSE/VRE = vancomycin-sensitive/resistant enterococci, MDR = multidrug resistant

*Remove/replace Foley catheter before initiating antibiotic therapy.

†No need to treat CAB in normal hosts, pre-emptive therapy suggested in compromised hosts, e..g.., cirrhosis, SLE, DM, myeloma, steroids, immunosuppressives, and those with renal insufficiency..

†† Longer courses of therapy may be needed in compromised hosts.. If pyuria substantially decreased after       2 days of therapy, complete 3 days of therapy.. If not, continue therapy for 7 days..

§  Only if oral therapy not possible..

	Chapter 2.  Empiric Therapy Based on Clinical Syndrome		105
Catheter Associated Candiduria (CAC)
Subset	Usual Pathogens	Therapy
Catheter	C.. albicans	Fluconazole 200 mg (PO) × 1 dose, then 100 mg (PO)
associated		q24h × 2 weeks
candiduria
	Fluconazole-resistant	Amphotericin B 0..3–0..6 mg/kg q24h × 1–7 days
(CAC)†*
	C.. albicans/non-albicans	or
	Candida	Flucytosine 25 mg/kg QID (PO) × 7–10 days
		or
		Amphotericin B bladder irrigation (continuous: 50 mg
		in 1 liter sterile water over 24h × 1–2 days; intermittent:
		50 mg in 200–300 ml sterile water q6-8h × 1–2 days)§

§Limited efficacy..

Clinical Presentation:  Indwelling urinary (Foley) catheter with bacteriuria and pyuria; no symptoms­ .. Diagnostic Considerations:  Pyuria plus bacteriuria/candiduria.. Usually afebrile or temperature < 101°F.. Pitfalls:  Bacteriuria/candiduria often represent colonization, not infection.. Persistent candiduria after amphotericin B deoxycholate bladder irrigation suggests renal candidiasis..

Therapeutic Considerations:  Avoid treating catheter-associated bacteriuria in normal hosts without GU tract abnormalities/disease.. Compromised hosts (diabetes, SLE, chronic steroids, multiple myeloma, cirrhosis) may require therapy for duration of catheterization.. If bacteriuria/candiduria does not clear with appropriate therapy, change the catheter.. For chronic renal failure/dialysis patients with candiduria, use amphotericin B deoxycholate bladder irrigation.. Efficacy of therapy of catheter-associated candiduria is limited and relapse is frequent unless the catheter can be replaced or (preferably) removed..

Prognosis:  Excellent in normal hosts. . Untreated bacteriuria/candiduria in compromised hosts may result in ascending infection (e..g.., pyelonephritis) or bacteremia/candidemia..

106 A n t i b i o t i c E s s e n t i a l s

Epididymitis

	Usual	Preferred IV	Alternate IV	PO Therapy or
Subset	Pathogens	Therapy	Therapy	IV-to-PO Switch
Acute	C.. trachomatis	Doxycycline	Levofloxacin	Doxycycline 200 mg
Young		200 mg (IV) q12h	500 mg (IV) q24h	(PO) q12h × 3 days,
males		× 3 days, then 100	× 7 days	then 100 mg (PO) q12h
		mg (IV) q12h ×		× 7 days*
		4 days		or
				Levofloxacin 500 mg
				(PO) q24h × 10 days
				or
				Ofloxacin 300 mg
				(PO) q12h × 10 days
Elderly	P.. aeruginosa	Cefepime	Ciprofloxacin	Ciprofloxacin 750 mg
males		2 gm (IV) q8h	400 mg (IV) q8h	(PO) q12h × 10 days
		× 10 days	× 10 days
		or	or
		Meropenem	Levofloxacin
		1 gm (IV) q8h	750 mg (IV) q24h
		× 10 days	× 10 days
Chronic	M.. tuberculosis	Treat the same as pulmonary TB (see p.. 53) or pulmonary
	Blastomyces	blastomycosis (see p.. 267)
	dermatiditis

Duration of therapy represents total time IV, PO, or IV + PO.. Most patients on IV therapy able to take PO meds should be switched to PO therapy soon after clinical improvement (usually < 72 hours)..

*Loading dose is not needed PO if given IV with the same drug..

Acute Epididymitis (Chlamydia trachomatis/Pseudomonas aeruginosa)

Clinical Presentation:  Acute unilateral testicular pain ± fever.. Diagnostic Considerations:  Ultrasound to rule out torsion or tumor.. Pitfalls:  Rule out torsion by absence of fever and ultrasound..

Therapeutic Considerations:  Young males respond to treatment slowly over 1 week.. Elderly males respond to anti-Pseudomonal therapy within 72 hours..

Prognosis:  Excellent in young males.. Related to health of host in elderly..

Chronic Epididymitis (Mycobacterium tuberculosis/ Blastomyces dermatiditis)

Clinical Presentation:  Chronic epididymoorchitis with epididymal nodules..

Diagnostic Considerations:  Diagnosis by AFB on biopsy/culture of epididymis. . TB epididymitis is always associated with renal TB.. Blastomyces epididymitis is a manifestation of systemic infection.. Pitfalls:  Vasculitis (e..g.., polyarteritis nodosum) and lymphomas may present the same way.. Therapeutic Considerations:  Treated the same as pulmonary TB/blastomycosis..

Prognosis:  Good..

Chapter 2.  Empiric Therapy Based on Clinical Syndrome

107

Acute Pyelonephritis (see Color Atlas for Urine Gram stains)

	Usual	Preferred IV	Alternate IV	PO Therapy or
Subset	Pathogens	Therapy	Therapy	IV-to-PO Switch
Acute	Entero-	Ceftriaxone	Meropenem 1 gm	Levofloxacin 500 mg
pyelonephritis	bacteriaceae	1 gm (IV) q24h	(IV) q8h × 2 weeks	(PO) q24h × 2 weeks
(Treat initially		× 2 weeks	or	or
		or	Aztreonam 2 gm (IV)	Amoxicillin 1 gm (PO)
based on urine
		Levofloxacin	q8h × 2 weeks	q8h ×2 weeks
gram stain; see
		500 mg (IV) q24h	or
therapeutic
considerations,		× 2 weeks	Gentamicin 240 mg
below)			(IV) q24h × 2 weeks
	Enterococcus	Ampicillin 1 gm (IV)	Quinolone (IV)	Amoxicillin 1 gm
	faecalis (VSE)§	q4h × 2 weeks	× 2 weeks	(PO) q8h × 2 weeks
		or		or
		Linezolid 600 mg		Linezolid 600 mg
		(IV) q12h × 2 weeks		(PO) q12h × 2
		or		weeks
		Meropenem 1 gm		or
		(IV) q8h ×2 weeks		Levofloxacin 500 mg
				(PO) q24h × 2 weeks
	Enterococcus	Linezolid 600 mg	Quinupristin/	Linezolid 600 mg
	faecium	(IV) q12h × 2 weeks	dalfopristin 7..5 mg/	(PO) q12h ×
	(VRE)		kg (IV) q8h × 2	2 weeks
			weeks	or
			or	Doxycycline 200
			Doxycycline 200 mg	mg (PO) q12h ×
			(IV) q12h × 3 days,	3 days, then 100
			then 100 mg q12h
				mg (PO) q12h × 2
			× 2 weeks
				weeks
	MDR	Meropenem 1 gm	Colistin 5 mg/kg (IV)
	GNB	(IV) q8h × 2 weeks	q8h × 2 weeks
		or
		Ceftolozane/
		tazobactam 1..5 gm
		(IV) q8h × 2 weeks
	CRE	Ceftazidime/	Tigecycline
		avibactam­ 2..5 gm	200 mg (IV) × 1 dose
		(IV) q8h × 2 weeks	then 100 mg (IV)
			q24h × 2 weeks*
			or
			Colistin 5 mg/kg (IV)
			q8h × 2 weeks

VSE/VRE = vancomycin-sensitive/resistant enterococci.

* Depending on MICs, higher doses may be necessary LD: 400 mg (IV) × 1 dose, then MD: 200 mg (IV) q24h.. § Treat vancomycin resistant E.. faecalis as VRE..

108 A n t i b i o t i c E s s e n t i a l s

Chronic Pyelonephritis/Renal TB

	Usual	Preferred IV	Alternate IV	PO Therapy or
Subset	Pathogens	Therapy	Therapy	IV-to-PO Switch
Chronic	Entero-	IV Therapy	Quinolone† (PO) × 4–6 weeks
pyelonephritis	bacteriaceae	Not applicable		or
			TMP–SMX 1 DS tab (PO) q12h × 4–6 weeks
				or
			Doxycycline 200 mg (PO) q12h × 3 days,
			then 100 mg (PO) q12h × 4–6 weeks total
Renal TB	M..	IV Therapy	Treated the same as pulmonary TB
	tuberculosis	Not applicable	(see p.. 53)

Duration of therapy represents total time IV, PO, or IV + PO.. Most patients on IV therapy able to take PO meds should be switched to PO therapy after clinical improvement (usually < 72 hours)..

†Ciprofloxacin XR 1000 mg (PO) q24h or Ciprofloxacin 400 mg (IV) q12h or Levofloxacin 500 mg (IV or PO) q24h..

Acute Bacterial Pyelonephritis (Enterobacteriaceae, E. faecalis/faecium)

Clinical Presentation:  Unilateral CVA tenderness with fevers ≥ 102°F..

Diagnostic Considerations:  Bacteriuria plus pyuria with unilateral CVA tenderness and temperature ≥ 102°F.. Bacteremia usually accompanies acute pyelonephritis; obtain blood and urine cultures.. Pitfalls:  Temperature decreases in 72 hours with or without antibiotic treatment.. If temperature does not fall after 72 hours of antibiotic therapy, suspect renal/perinephric abscess..

Therapeutic Considerations:  Initial treatment is based on the urinary gram stain: If gram-negative bacilli, treat as Enterobacteriaceae.. If gram-positive cocci in chains (enterococcus), treat as E.. faecalis; if enterococcus is subsequently identified as E.. faecium, treat accordingly.. Acute pyelonephritis is ­usually treated initially for 1–3 days IV, then switched to PO to complete 4 weeks of antibiotics to minimize­ progression to chronic pyelonephritis.. Obtain a CT/MRI in persistently febrile patients after 72 hours of antibiotics to rule out renal calculi, obstruction, abscess, or xanthomatous pyelonephritis..

Prognosis:  Excellent if first episode is adequately treated with antibiotics for 4 weeks..

Chronic Bacterial Pyelonephritis (Enterobacteriaceae)

Clinical Presentation:  Previous history of acute pyelonephritis with same symptoms as acute pyelonephritis but less CVA tenderness/fever..

Diagnostic Considerations:  Diagnosis by CT/MRI showing changes of chronic pyelonephritis plus bacteriuria/pyuria.. Urine cultures may be intermittently negative before treatment.. Chronic pyelonephritis is bilateral pathologically, but unilateral clinically..

Pitfalls:  Urine culture may be intermittently positive after treatment; repeat weekly ×4 to confirm urine remains culture-negative..

Therapeutic Considerations:  Treat ×4–6 weeks.. Impaired medullary vascular blood supply/renal anatomical distortion makes eradication of pathogen difficult..

Prognosis:  Related to extent of renal damage..

Chapter 2.  Empiric Therapy Based on Clinical Syndrome

109

Renal TB (Mycobacterium tuberculosis)

Clinical Presentation:  Renal mass lesion with ureteral abnormalities (pipestem, corkscrew, or spiral ureters) microscopic hematuria/sterile pyuria.. Painless unless complicated by ureteral obstruction.. Diagnostic Considerations:  Combined upper/lower urinary tract abnormalities ± microscopic hematuria/urinary pH ≤ 5..5.. Diagnosis by culture of TB from urine.. Urine TB PCR is specific, but not very sensitive..

Pitfalls:  Chest x-ray is normal in 50%, but most patients are PPD positive.. Rule out other infectious/ inflammatory causes of sterile pyuria (e..g.., Trichomonas, interstitial nephritis)..

Therapeutic Considerations:  Treat the same as pulmonary TB..

Prognosis:  Good if treated before renal parenchymal destruction/ureteral obstruction occur..

Renal Abscess (Intrarenal/Perinephric)

				PO Therapy
	Usual	Preferred	Alternate IV	or IV-to-PO
Subset	Pathogens	IV Therapy	Therapy	Switch
Cortical	S.. aureus	MSSA:	MSSA	MSSA/MRSA
(Treat		Nafcillin 2 gm (IV) q4h*	Meropenem	Linezolid 600
		or	1 gm (IV) q8h*	mg (PO) q12h*
initially for
		Ceftriaxone 1 gm (IV)	or	or
MSSA; if
		q24h*	Ertapenem 1	Minocycline 100
later
identified		or	gm (IV) q24h*	mg (PO) q12h*
as MRSA,		Clindamycin 600 mg
treat		(IV) q8h*
accordingly)
		MRSA: Linezolid 600 mg	MRSA
		(IV) q12h*	Vancomycin 1
		or	gm (IV) q12h*
		Minocycline 100 mg (IV)
		q12h*
Medullary	Entero-	Quinolone (IV)†*	TMP–SMX 2..5	Quinolone
	bacteriaceae		mg/kg (IV)	(PO)†*
			q6h*

MSSA/MRSA = methicillin-sensitive/resistant S.. aureus.. Duration of therapy represents total time IV, PO, or IV + PO.. Most patients on IV therapy able to take PO meds should be switched to PO therapy soon after clinical improvement..

* Treat until renal abscess resolves completely or is no longer decreasing in size on CT/MRI..

†Levofloxacin 500 mg (IV/PO) q24h..

Clinical Presentation:  Similar to pyelonephritis but fever remains elevated after 72 hours of antibiotics­.. Diagnostic Considerations:  Obtain CT/MRI to diagnose perinephric/intra-renal abscess and rule out mass lesion.. Cortical abscesses are usually secondary to hematogenous/contiguous spread.. Medullary abscesses are usually due to extension of intrarenal infection..

110 A n t i b i o t i c E s s e n t i a l s

Pitfalls:  Urine cultures may be negative with cortical abscesses..

Therapeutic Considerations:  Most large abscesses need to be drained.. Multiple small abscesses are managed medically.. Obtain urology consult..

Prognosis:  Related to degree of baseline renal dysfunction..

Prostatitis/Prostatic Abscess

					PO Therapy or
	Usual	Preferred IV	Alternate IV		IV-to-PO
Subset	Pathogens	Therapy	Therapy		Switch
Acute	Entero-	Quinolone* (IV)	TMP–SMX		Quinolone* (PO)
prostatitis/	bacteriaceae	× 2 weeks	2..5 mg/kg (IV) q6h		× 2 weeks
acute		or	× 2 weeks		or
prostatic		Ceftriaxone	or		Doxycycline
abscess		1 gm (IV) q24h	Aztreonam		200 mg (PO)
		× 2 weeks	2 gm (IV) q8h		q12h × 3 days,
			× 2 weeks		then 100 mg
					(PO) q24h × 11
					days
					or
					TMP–SMX
					1 SS tablet (PO)
					q12h × 2 weeks
Chronic	Entero-		Quinolone* (PO) × 1–3 months
prostatitis	bacteriaceae			or
			TMP–SMX 1 DS tablet (PO) q12h × 1–3
			months
	MDR GNB		Fosfomycin 3 gm (PO) q48h × 30 days
				±
			Doxycycline 100 mg (PO) q24h × 1–3
			months

Duration of therapy represents total time IV, PO, or IV + PO.. Most patients on IV therapy able to take PO meds should be switched to PO therapy soon after clinical improvement (usually < 72 hours)..

*Ciprofloxacin XR 1000 mg (PO) q24h or Ciprofloxacin 400 mg (IV) q12h or Levofloxacin 500 mg (IV or PO) q24h..

Acute Prostatitis/Acute Prostatic Abscess (Enterobacteriaceae)

Clinical Presentation:  Acute prostatitis presents as an acute febrile illness in males with dysuria and no CVA tenderness.. Prostatic abscess presents with hectic/septic fevers without localizing signs.. Diagnostic Considerations:  Acute prostatitis is diagnosed by bacteriuria, pyuria plus mucus threads, with exquisite prostate tenderness, and is seen primarily in young males.. Positive urine culture is due to contamination of urine as it passes through infected prostate.. Prostatic abscess is diagnosed by transrectal ultrasound or CT/MRI of prostate..

Chapter 2.  Empiric Therapy Based on Clinical Syndrome

111

Pitfalls:  Do not overlook acute prostatitis in males with bacteriuria without localizing signs, or prostatic­ abscess in patients with a history of prostatitis..

Therapeutic Considerations:  Treat acute prostatitis for 2 full weeks to decrease progression to chronic prostatitis.. Prostatic abscess is treated the same as acute prostatitis plus surgical drainage..

Prognosis:  Excellent if treated early with full course of antibiotics (plus drainage for prostatic abscess)..

Chronic Prostatitis (Enterobacteriaceae/MDR GNB)

Clinical Presentation:  Vague urinary symptoms (mild dysuria ± low back pain), history of acute prostatitis, and little or no fever..

Diagnostic Considerations:  Diagnosis by bacteriuria plus pyuria with mucus threads ± mild prostate tenderness.. Urine, semen, or prostate expressate are culture positive..

Pitfalls:  Commonest cause of treatment failure is inadequate duration of therapy.. Chronic prostatitis with prostatic calcifications (transrectal ultrasound) will not clear with antibiotics; transurethral resection of prostate (TURP) with removal of all calcifications curative..

Therapeutic Considerations:  In sulfa-allergic patients, TMP alone may be used in place of TMP–SMX.. Prognosis:  Excellent if treated × 1–3 months.. Prostatic abscess is a rare but serious complication (may cause urosepsis)..

Urosepsis (see Color Atlas for Urine Gram stains)

	Usual		Alternate IV
Subset	Pathogens	Preferred IV Therapy	Therapy	IV-to-PO Switch
Community	Entero-	Ceftriaxone 1 gm (IV)	Amikacin 1 gm (IV)	Levofloxacin
acquired	bacteriaceae	q24h × 7 days*	q24h × 7 days*	500 mg (PO) q24h ×
(Treat initially	(ESBL–)	or	or	7 days*
		Levofloxacin	Aztreonam 2 gm	or
based on urine
		500 mg (IV) q24h ×	(IV) q8h × 7 days*	TMP–SMX 1 SS tablet
gram stain)
		7 days*		(PO) q12h × 7 days*
	(ESBL +)	Meropenem 1 gm (IV)	Doripenem 1 gm	Fosfomycin 3 gm
		of q8h × 7 days*	(IV) of q8h × 7 days*	(PO) q 3 days × 7
				days*
	E.. faecalis (VSE)	Ampicillin 2 gm (IV)	Meropenem	Amoxicillin 1 gm (PO)
	Group B	q4h × 7 days*	1 gm (IV) q8h × 7	q8h × 7 days*
	streptococci		days*	or
				Levofloxacin
				500 mg (PO) q24h ×
				7 days*
(No urine	Entero-	Meropenem 1 gm (IV)	Piperacillin/	Levofloxacin
gram stain)	bacteriaceae	q8h × 7 days*	tazobactam 3..375	500 mg (PO) q24h ×
	E.. faecalis (VSE)		mg (IV) q6h ×7 days*	7 days*
	Group B
	streptococci

* Longer duration needed if urologic/renal abnormalities present..

112	A n t i b i o t i c E s s e n t i a l s

Urosepsis (cont’d) (see Color Atlas of Urine Gram stains)

	Usual	Alternate IV
Subset	Pathogens Preferred IV Therapy	Therapy	IV-to-PO Switch

Related to urological procedure

(Treat intially for P.. aeruginosa, etc; if later identified as nonaeruginosa

Pseudomonas, treat accordingly)

P.. aeruginosa	Meropenem 1 gm (IV)	Doripenem 1 gm	Ciprofloxacin 750 mg
Enterobacter	q8h × 7 days	(IV) q8h × 7 days	(PO) q12h × 7 days
Klebsiella	or	or	or
Serratia	Levofloxacin 750 mg (IV)	Aztreonam 2 gm (IV)	Levofloxacin 750 mg
	q24h ×7 days	q8h × 7 days	(PO) q24h × 7 days
	or	or
		Amikacin 1 gm (IV)
	Cefepime 2 gm (IV)
		q24h × 7 days
	q8h × 7 days
		or
		Ciprofloxacin 400 mg
		(IV) q8h ×7 days
MDR	Meropenem 1 gm (IV)	Colistin 5 mg/kg (IV)
GNB	q8h × 2 weeks	q8h × 2 weeks
	or
	Ceftolozane/
	tazobactam 1..5 gm (IV)
	q8h × 2 weeks
CRE	Ceftazidime/	Colistin 5 mg/kg (IV)
	avibactam­ 2..5 gm (IV)	q8h × 2 weeks
	q8h × 2 weeks
	or
	Tigecycline 200 mg
	(IV) × 1 dose then
	100 mg (IV) q24h × 2
	weeks*

*Depending on MICs, higher doses may be necessary LD: 400 mg (IV) × 1 dose, then MD: 200 mg (IV) q24h..

Community-Acquired Urosepsis

Clinical Presentation:  Sepsis from urinary tract source..

Diagnostic Considerations:  Blood and urine cultures positive for same uropathogen.. If patient does not have diabetes, SLE, cirrhosis, myeloma, steroids, pre-existing renal disease or obstruction, obtain CT/ MRI of GU tract to rule out abscess/obstruction.. Prostatic abscess is rarely a cause of urosepsis..

Pitfalls:  Mixed gram-positive/negative urine cultures suggest specimen contamination or enterovesicular fistula..

Therapeutic Considerations:  Empiric treatment is based on urine gram stain. . If urine gram stain shows pyuria and gram-positive cocci, treat as group D enterococci (E.. faecalis-VSE).. If gram-negative bacilli, treat as Enterobacteriaceae.. S.. aureus/S.. pneumoniae are not uropathogens..

Prognosis:  Related to severity of underlying condition causing urosepsis and health of host..

Urosepsis Following Urological Procedures

Clinical Presentation:  Sepsis within 24 hours after GU procedure..

Diagnostic Considerations:  Blood and urine cultures positive for same uropathogen. . Use preprocedural urine culture to identify uropathogen and guide therapy..

Pitfalls:  If non-aeruginosa Pseudomonas in urine/blood, switch to TMP–SMX pending susceptibilities.. Therapeutic Considerations:  Empiric P.. aeruginosa monotherapy will cover most other uropathogens..

Prognosis:  Related to severity of underlying condition causing urosepsis and health of host..

Chapter 2.  Empiric Therapy Based on Clinical Syndrome

113

Pelvic Inflammatory Disease (PID), Salpingitis, Tuboovarian

Abscess, Endometritis/Endomyometritis, Septic Abortion

	Usual		PO Therapy or
Subset	Pathogens	IV Therapy	IV-to-PO Switch
Hospitalized	B.. fragilis	Monotherapy with	Monotherapy with
patients†	Entero-	Moxifloxacin 400 mg (IV) q24h × 2 weeks	Moxifloxacin 400 mg
	bacteriaceae	or combination therapy with	(PO) q24h × 2 weeks
	N.. gonorrhoeae	Doxycycline 200 mg (IV) q12h × 3 days,
	C.. trachomatis	then 100 mg (IV) q12h × 11 days
	C.. sordelli§	plus either
	(septic abortion)	Piperacillin/tazobactam 4..5 gm (IV) q8h
		× 2 weeks or Ertapenem 1 gm (IV) q24h
		× 3–10 days or Cefoxitin 2 gm (IV) q6h
		× 2 weeks or Cefotetan 2 gm (IV) q12h
		× 2 weeks
		Alternate combination therapy
		Doxycycline 200 mg (IV) q12h × 3 days,
		then 100 mg (IV) q12h × 11 days plus
		Ampicillin/sulbactam 3 gm (IV) q6h ×
		2 weeks or Quinolone‡ (IV) q24h × 2
		weeks plus Metronidazole 1 gm (IV)
		q24h × 2 weeks
Outpatients	N.. gonorrhoeae	Moxifloxacin 400 mg (PO) q24h × 2 weeks** or Doxycycline 100
(mild PID	C.. trachomatis B..	mg (PO) q12h × 2 weeks
only)	fragilis
	Entero-
	bacteriaceae

Duration of therapy represents total time IV, PO, or IV + PO.. Most patients on IV therapy able to take PO meds should be switched to PO therapy after clinical improvement..

†Treat only IV or IV-to-PO switch for salpingitis, tuboovarian abscess, endometritis, endomyometritis, septic abortion, or severe PID..

‡Levofloxacin 500 mg (IV or PO) q24h or Ofloxacin 400 mg (IV or PO) q12h..

** Recent gonococcal resistance to quinolones requires careful follow-up during/after therapy..

§Antibiotic therapy of septic abortion same as salpingitis/endometritis plus evacuation of uterine ­contents..

Clinical Presentation:  PID/salpingitis presents with cervical motion/adnexal tenderness, lower quadrant abdominal pain, and fever.. Endometritis/endomyometritis presents with uterine tenderness ± cervical discharge/fever.. Endomyometritis is the most common postpartum infection..

Diagnostic Considerations:  Unilateral lower abdominal pain in a female without a non-pelvic cause suggests PID/salpingitis..

Pitfalls:  Obtain CT/MRI of abdomen/pelvis to confirm diagnosis and rule out other pathology or tuboovarian abscess..

Therapeutic Considerations:  Tuboovarian abscess usually requires drainage/removal ± TAH/BSO, plus antibiotics (see p.. 113) × 1–2 weeks after drainage/removal.. Septic abortion is treated the same as endometritis/endomyometritis plus uterine evacuation..