How are urinary tract infections treated?

How are urinary tract infections treated?

How are urinary tract infections treated?

1. Paediatric UTIs

Typically, oral fluids and antibiotics are the primary means of treatment for children affected by either uncomplicated or complicated UTIs.

Intravenously administered fluids and antibiotics will be given to children with severe or uroseptic conditions (sepsis that is localised to the urinary tract) in hospital. A child will also be hospitalised if he or she has signs of a urinary obstruction, another underlying medical condition, is unable to tolerate medications or orally taken fluids, or is younger than 1 month old. Babies 2 months and younger with signs of kidney infection with also be hospitalised once diagnosed.

Infants (2 months and younger) displaying UTI symptoms with fever (due to bacterial causes)
Hospital care will involve the following:

Parenteral antibiotic therapy (daily doses) for complicated UTI and pyelonephritis:

  • Ceftriaxone / Rocephin (prescribed for infants older than 6 weeks) – This medication is most often used for UTIs as a result of infection with E. coli, Klebsiella pneumoniae, Morganella morganii, Proteus mirabilis and Proteus vulgaris bacterium. It is also effective for complicated kidney infections.
  • Cefotaxime / Claforan (this is considered safe for babies who are younger than 6 weeks old and often used with ampicillin for between 2 and 8 weeks) – This medication is effective in treating acute, complicated kidney infections, as well as babies who are affected by jaundice. Doses will usually be given every 6 to 8 hours.
  • Ampicillin / Marcillin, Omnipen, Polycillin (often prescribed with gentamicin in infants younger than 2 weeks old) – This medication is also effective in treating acute kidney infections (with or without bacterial organisms present in the urine), as well as UTIs as a result from E. coli and Proteus mirabilis bacteria.
  • Gentamicin (blood levels and kidney function will typically be tested every 48 hours) – This medication is a good alternative to the aforementioned medications should signs of allergy occur in a paediatric patient. It is effective in treating complicated UTIs and can be used in combination with any of the previously mentioned medications.

Antibiotics may be administered daily with dosages depending on an infant’s age. Monitoring of a child will take place daily until his or her fever has broken. Intravenous antibiotics will likely continue to be administered for between 24 and 36 hours once a fever has subsided, and the child begins to show improvement.

Oral antibiotics will not normally be prescribed to infants who are considered toxic (acutely or severely ill or who have complicated UTIs), display moderate to severe signs of dehydration, or who vomit persistently. Oral therapy is usually only an option for paediatric patients who are able to retain the medication, but this can be substituted with intravenously administered antibiotics if necessary.

An infant will normally be discharged from hospital within 48 to 72 hours and continue antibiotic therapy at home. Oral antibiotic therapy may be prescribed for between 10 and 14 days thereafter to clear the bacterial infection.

Oral antibiotic therapy for children (dosages per day according to a child’s weight)
  • Sulfamethoxazole / Bactrim, Cotrim, Septra: 30 to 60 mg per kilogram (every 12 hours) – This medication is effective for the treatment and prevention of UTIs and is available in both tablet and suspension (mixed with liquid) forms.
  • Trimethoprim / Primsol: 6 to 12 mg per kilogram (every 12 hours) – This medication is effective for preventing further infections by hindering the production of tetrahydrofolic acid commonly found in bacteria organisms. This medication is classified as a dihydrofolate reductase inhibitor.
  • Amoxicillin and clavulanic acid: / Augmentin, Amoclan: 20 to 40 mg per kilogram (every 8 hours) – This medication can treat UTIs by binding to penicillin-binding proteins, inhibiting bacterial synthesis (bacteria use proteins for a variety of functions necessary to their existence, preventing synthesis kills of bacteria, thus treating infection). Clavulanate also inhibits beta-lactamase enzymes (these are enzymes that bacteria produce which make them resistant to certain antibiotics). Oral suspensions are also available for children.
  • Cephalexin / Keflex: 50 to 100 mg per kilogram (every 6 hours) – This medication is effective for UTIs caused by bacteria and can also be used in a preventative capacity for infants between 6 and 8 weeks old.
  • Cefixime / Suprax: 8 mg per kilogram (every 24 hours) – This medication is effective for treating acute bacterial UTIs, binding to penicillin-binding proteins and hindering synthesis of bacterial organisms (i.e. stunting bacterial growth).
  • Cefpodoxime: 10 mg per kilogram (every 12 hours) – This medication is effective for the treatment of acute bacterial UTIs caused by bacterium that can proliferate with or without oxygen (aerobic and anaerobic micro-organisms).
  • Nitrofurantoin / Furadantin, Macrobid, Macrodantin (for bladder infection treatment) – 5 to 7 mg per kilogram (every 6 hours) – This medication is primarily used for lower urinary tract infections (at low dosage concentrations) and can also be used in a preventative capacity (preventing potential reinfection at higher dosage concentrations). This drug inhibits acetylcoenzyme by interfering with the metabolism of bacterial carbohydrates.

Antibiotics will be selected with current drug resistance data in mind but should generally be able to effectively treat all known UTI pathogen organisms. Oral antibiotics may be prescribed for between 4 and 7 days, thereafter a follow-up doctor’s appointment will be recommended to assess the efficiency of treatment and whether the infection has cleared.

Bladder infections (cystitis) will typically be treated with a 4-day course of antibiotics. If no improvement is noted after 2 to 3 days of antibiotic treatment, a doctor may reassess a child’s condition and the antibiotic prescribed, selecting another which may be more beneficial.

An increase in fluid intake will also be recommended so as to encourage urine dilution and frequency of urination while on treatment. Treatment for bladder infections may also include of the administration of NSAIDs (non-steroidal anti-inflammatory drugs like Ibuprofen) and acetaminophen (Tylenol, Cetafen, Acephen or Mapap) to assist in alleviating symptoms of pain associated with urination.

2. Adult UTIs – female

Treatment for adult women (non-pregnant patients)

Female patients who do not show signs of any urinary tract obstructions and do not have a recent history of catheterisation will generally be diagnosed with uncomplicated UTIs. Prescribed medication is typically the recommended means of treatment once a UTI has been diagnosed.

Antibiotics are aimed at clearing an infection, as well as preventing further infection complications (such as an infection of the kidneys). Medications (analgesics such as Phenazopyridine) to help alleviate any discomfort and pain associated with urination may also be recommended following a diagnosis for between 1 and 2 days. Drinking plenty of fluids will also be recommended to encourage dilution of urine flow.

Complicated infections are normally associated with underlying medical conditions, more persistent symptoms, kidney dysfunction, anatomic abnormalities (of the urinary tract), catheters, kidney transplant recipients or individuals with compromised immune systems. Complicated infections tend to be at higher risk of medication therapy failure. Symptoms tend to persist for at least 7 days in complicated cases.

Most of the recommended antibiotics are known to be effective against strains / species of E. coli, enterococci, Staphylococcus aureus, Klebisiella, Enterobacter, Proteus and Shigella pathogens. Ahead of prescribing any (oral) antibiotic options, a doctor will have assessed the current drug resistance patterns and recommend those which would be expected to be most effective at the time of diagnosis.

As the most common form of urinary tract infection in women, uncomplicated cystitis will typically be treated with the following:
  • Trimethoprim or Sulfamethoxazole (Bactrim, Bactrim DS, Septra and Septra DS): 160 – 800mg tablets to be taken orally – recommended dosage tablets are taken twice a day for 3 days. These medications are typically not prescribed to senior patients due to an increased risk of impairment to kidney function.
  • Nitrofurantoin monohydrate / macrocystals (Furadantin, Macrobid, Macordantin): Nitrofurantoin monohydrate/macrocrystals can be taken at 100 mg twice a day for between 5 and 7 days. Nitrofurantoin macrocrystals can be taken at dosages between 50 and 100 mg four times a day for 7 days. The medication is available in macrocrystals (Macrodantin) and microcrystal / suspension (Furadantin) forms in order to adequately treat an infection with varying concentrations of the drug in urine (as appropriately determined by the treating doctor). Combination treatment may be recommended in cases of acute infection. These medications will not likely be recommended to any woman who has signs and symptoms of an early kidney infection.
  • Fosfomycin (Monurol): 3 mg taken as a single dose with 88 to 118 millilitres of water. Concentrations of the medication remain high in the urine for between 24 and 48 hours after the dose is taken.
  • Ciprofloxacin (Cipro, Proquin XR / extended release): 250 mg taken twice a day for 3 days. Duration of therapy can be extended should an infection not show signs of clearing or if it worsens. Extended release dosages can be given at 500 mg a day for 3 days.
  • Ofloxacin: 200 mg taken twice a day for 3 days. This medication is effective for treating lower urinary tract infections that are uncomplicated or complicated. Complicated conditions can be treated with daily dosages for up to 10 days.
  • Levofloxacin (Levaquin): 250 mg taken once every 24 hours for 3 days. Doses for complicated lower urinary tract infections can be recommended at 750 mg taken once a day for 5 days or at 250 mg once a day for 10 days.
Alternative treatment options can include:
  • Amoxicillin / Clavulanate (Augmentin and Augmentin XR / extended release): 500 mg/125 mg taken daily for between 3 and 7 days. An alternative dosage recommendation is 250 mg / 125 taken daily for between 3 and 7 days. This medication is not typically a first-choice treatment for adult females but is effective where any of the aforementioned medications may not be entirely suitable for a patient.
  • Ampicillin: This alternative medication can be given intravenously or injected intramuscularly (often used along with Gentamicin) to treat infections in instances where a patient has difficulty tolerating oral antibiotics or if resistance to previous treatment is suspected or identified.
  • Cefdinir: This medication is sometimes used as an alternative when others have not been found to be as effective for clearing an infection. Dosages are typically recommended at 300 mg, taken twice daily for 7 days.
  • Cefaclor: This medication is an option for infections of the bladder and kidneys and is generally recommended at a dose of 500 mg, taken three times a day for 7 days (in uncomplicated infections).
  • Cefpodoxime: Another alternative, this medication can be taken at 100 mg, twice daily for 7 days.
  • Cefuroxime: Dosage recommendation for this medication is 250 mg, taken twice daily for between 7 and 10 days.
Other alternatives include:
  • Ceftazidime (Fortaz and Tazicef) – For the treatment of complicated and uncomplicated UTIs
  • Cefepime (Maxipime) – Used in the treatment of complicated and uncomplicated UTIs
  • Gentamicin – Used in combination with ampicillin in the treatment of complicated UTIs
  • Doripenem (Doribax) – Administered in the treatment of complicated UTIs, including kidney infections
  • Imipenem/cilastatin (Primaxin) – Used to treat kidney infections
  • Meropenem (Merrem) – To treat complicated lower urinary tract infections
Complicated lower urinary tract infections are treated with the following:
  • Oral antibiotics: Ciprofloxacin (dosages taken for between 7 and 14 days) and Levofloxacin (dosages taken for 5 days).
  • Parenteral antibiotics: Ciprofloxacin (dosages given for between 7 and 14 days), Levofloxacin (dosages given for 5 days), Ampicillin and Gentamicin (dosages given for between 7 and 14 days), Piperacillin-tazobactam (dosages given every 6 hours), Doripenem (dosages given for 10 days), Impenem-cilastatin (dosages given for between 7 and 14 days), and Meropenem (dosages given for between 7 and 14 days).

If a patient shows signs of rapid improvement within the first few days of treatment, dosages may be halted at around 7 days. Older female patients are also generally treated for a period of at least 7 days, especially if it is determined that an infection has occurred as a result of Staphylococcus saprophyticus microorganisms. Should treatment responses show slow or delayed improvements or if a woman is hospitalised with a complicated infection, treatment may be recommended over 10 to 14 days.

Treatment for pregnant adult women

Antibiotics will be recommended for pregnant women with either symptomatic or asymptomatic infections but will be selected with caution. A doctor will take into careful consideration the potential risks of complications as they apply to both the mother and unborn baby and all of these will be discussed ahead of treatment commencement, ensuring that the option with the best therapeutic outcome and safety profile is selected.

Oral antibiotics regarded as safe to use during pregnancy in the treatment of a UTI include:

  • Nitrofurantoin monohydrate / macrocrystals: 100 mg taken twice a day for at least 5 and 7 days.
  • Amoxicillin and Amoxicillin-clavulanate: 500 mg taken twice daily for at least 5 and 7 days. Alternatively, 250 mg can be taken three times daily for at least 5 to 7 days.
  • Cephalexin: 500 mg taken twice a day for at least 3 to 7 days.
  • Fosfomycin: 3 grams taken orally as a single dose with water.

Oral antibiotics for treating bladder infections and bacteriuria during pregnancy:

  • Cephalexin: Dosages are recommended at 500 mg, taken 4 times a day.
  • Ampicillin: Dosages are recommended at 500 mg, taken 4 times a day.
  • Nitrofurantoin: Dosages are recommended at 100 mg, taken twice a day.
  • Sulfisoxazole: Dosages are recommended at 1 gram, taken 4 times a day.

A doctor is likely to recommend longer courses of antibiotic treatment for pregnant women (although initial courses may be prescribed between 3 and 7 days), normally between 10 and 14 days to effectively achieve higher clearance rates of the infecting pathogen. A doctor may also recommend a urine culture within a week or two of antibiotic treatment commencement to assess the effectiveness of the selected drug and whether bacterial microorganisms are still present in the urine or not.

Medications which will not typically be prescribed to a pregnant woman include:

  • Tetracyclines: These are known to potentially cause congenital defects affecting the teeth and bone structures of the developing baby.
  • Trimethoprim: Facial defects and cardiac abnormalities may occur with the use of this medication, specifically during the first trimester.
  • Chloramphenicol: The use of this antibiotic during pregnancy can result in toxicity that causes a rare condition known as gray syndrome / gray baby syndrome which leads to low blood pressure, cyanosis due to a lack of oxygen in the blood and may be fatal if left untreated.
  • Sulfonamides: During a woman’s third trimester, the use of these medications can result in complications such as haemolytic anaemia (anaemia due to abnormal degradation of the red blood cells), jaundice or kernicterus (a form of brain damage as a result of high bilirubin levels in a baby’s bloodstream).

Treatment guidelines for kidney infections in pregnant women

If pyelonephritis is determined during initial consultation and testing procedures, a woman will likely be hospitalised for treatment. She will be given intravenously administered antibiotics (such as Gentamicin) and fluids to alleviate dehydration following bouts of nausea and vomiting. Intravenously administered fluids will be given with caution so as to avoid possible complications such as pulmonary oedema (excess fluid in the lungs) or acute respiratory distress syndrome (ARDS).

If a woman has a high fever, acetaminophen will usually be given to alleviate the symptom. Antiemetic medications (safe for pregnancy) can also be recommended if a woman is struggling with nausea and vomiting (which can also occur as a side-effect of antibiotic treatment).

Treating physicians will keep a watchful eye on their pregnant patient during hospitalised treatment so as to avoid spontaneous miscarriage or preterm labour / delivery of an unborn baby while infections are being cleared with medications.

Surgical treatment of complicated UTI during pregnancy

It is rarely required but, in some instances, a surgical procedure may be required to treat a complicated UTI. Some instances that may warrant surgery include:

  • Bladder diverticulum (often as a result of bladder obstructions or urethral scar tissue)
  • Bladder stones
  • Urethral syndrome (painful inflammation of the urethra)
  • Lower urinary tract trauma
  • Bladder cancer
  • Interstitial cystitis (severe pain in the bladder)

If any procedures are required, it is generally recommended that they only be performed during a woman’s second trimester. Earlier surgical intervention may result in miscarriage. Intervention during the third trimester may induce preterm labour. If surgical procedures are required during the third trimester, these will typically be scheduled to coincide with the birth of a baby.

3. Adult UTIs – male

It is general practice to regard all male UTIs as complicated infections due to the fact that most infections occur in either infant or elderly males due to abnormalities of the urinary tract. (14) As such, treatment will be targeted to clear infections of both the lower and upper urinary tract. During diagnosis, the results of a urine culture may provide some drug adjustment consideration, especially if a known resistant organism is prevalent at the time of infection.

Senior males will be treated with particular caution, especially if a kidney infection is identified. Younger, sexually active males will be treated with both UTI symptoms and possible STD-associated factors.

Before treatment commences, males will be referred to a urologist if any of the following are identified:
  • Anatomic abnormality
  • Signs of an acute scrotum
  • Indications of prostatitis (inflammation of the prostate)
Other pre-treatment consultations may be recommended in the following instances:
  • If there are indications of unusual or resistant microorganisms. In this instance, a male patient will be referred to an infectious disease specialist.
  • If a male patient has been using aminoglycosides for bacterial condition treatment already, he may be referred to a pharmacokinetics specialist for a consultation. This is to assess the possible risk of complications associated with the use of these medications which may include cranial nerve damage (which may result in hearing loss or vestibular dysfunction, such as dizziness or vertigo)
  • In the case of non-bacterial prostatitis, a pain specialist may be consulted in order to assist in alleviating symptoms of discomfort.
Antibiotic treatment for male UTI and related conditions

As with females and children, antibiotic treatment is aimed at clearing infection, as well as reducing or preventing further complications.

Male patients who have comorbid conditions, urinary tract obstruction, compromised immune systems, symptoms of dehydration, rigor (body chills) or hyperpyrexia (extreme elevations in core body temperature), who cannot care for themselves at home (e.g. elderly patients) or who are unable to maintain hydration orally themselves may be hospitalised for treatment.

In hospital, patients will be treated with intravenously administered antibiotics (antimicrobial therapy):
  • Ceftriaxone
  • Ciprofloxacin
Antibiotic treatment for male UTI symptoms (and related bacterial conditions) will include the following options:
  • Ciprofloxacin (Cipro): Treatment of UTIs and chronic bacterial prostatitis.
  • Levofloxacin (Levaquin): Treatment of UTIs and chronic bacterial prostatitis.
  • Ofloxacin (Floxin): Treatment of prostatitis infections caused by E. coli.
  • Norfloxacin (Noroxin): Treatment of UTIs and prostatitis caused by E. coli.
  • Trimethoprim (Proloprim, Trimpex): Treatment of UTIs.
  • Trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS): Treatment of UTIs (may not be recommended in the effective treatment of kidney infections).
  • Ampicillin (Omnipen, Polycillin, Principen): Treatment of UTIs.
  • Amoxicillin (Moxatag, Trimox): Treatment of UTIs.
  • Gentamicin (Garamycin, Gentacidin): Treatment of UTIs.
  • Ceftriaxone (Rocephin): Treatment of UTIs.
  • Ceftazidime (Fortaz, Tazicef): Treatment of UTIs.
  • Tobramycin (TOBI): Treatment of UTIs.
  • Erythromycin (Erythrocin, Ery-Tab): Treatment of UTIs caused by staphylococcal and streptococcal species.
  • Vancomycin (Vancocin, Vibra-Tabs): Treatment of urinary tract infections caused by enterococcus species. This medication may sometimes be recommended for patients who have not seen improvement with other drugs in treating staphylococci species infections.
  • Doxycycline (Vibramycin, Vibra-Tabs): Treatment of UTIs.
  • Ertapenem (Invanz): Treatment of urinary tract infections.
  • Aztreonam (Azactam, Cayston): Treatment of UTIs and is an option for those with allergic responses to other antibiotics.
  • Nitrofurantoin (Macrodantin, Furadantin): Treatment of UTIs (specifically bladder infections) caused by species of E coli, enterococci, staphylococcus aureus, Klebsiella and Enterobacter.

Antipyretic (fever reducing) and analgesic (pain relieving) medications, such as Phenazopyridine, along with intravenously administered fluids will also be given to ensure that an adequate flow of urine is encouraged. Antibiotic treatment for male UTI symptoms is generally recommended over a 10 to 14-day period.

The selection of antibiotic therapy and dosages will be carefully recommended according to location of infection, type pf pathogen and associated conditions which include:

  • Acute or chronic prostatitis / prostate inflammation (ampicillin and gentamicin)
  • Epididymitis / inflammation of the epididymis (ceftriaxone and doxycycline)
  • Pyelonephritis / kidney infection (aminoglycoside and ampicillin administered intravenously until a fever has subsided for at least 24 hours. Fourteen to 30 days of oral antibiotic treatment may follow.)
  • Cystitis / bladder infection (fluoroquinolone medications are recommended for between 7 and 10 days)
  • Urethritis / urethral infection (ceftriaxone – effective for treatment of gonococcal and nongonococcal urethritis)

Surgical procedures may be required to address issues such as obstructions. A bladder neck obstruction may be corrected with a transurethral incision of the bladder neck. If a part of the infected prostate gland requires removal, a partial transurethral proctectomy (TURP) may be recommended. An orchidopexy procedure can help to resolve torsions of the testicles and scrotum.

Along with antibiotic treatment, a doctor will highly recommend adequate hydration. He or she may also recommend an intake of foods and supplements that are rich in magnesium and phosphorus (these types of foods include dairy products, or dark green and leafy vegetables). A doctor will also encourage bedrest and the avoidance of physical activities such as bike riding for several weeks.

Sexual activity may resume when a patient and his partner have been cleared of infection with antibiotic treatment. Birth control methods, like use of condoms may be encouraged to reduce risk of potential infections in future.

Reference:

14. Cleveland Clinic. November 2013. Acute Uncomplicated Urinary Tract Infections: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/urinary-tract-infection/  [Accessed 28.03.2018]

PREVIOUS How are urinary tract infections diagnosed?
NEXT Complications of urinary tract infections