Suspected UTI in a non-pregnant adult
Dysuria, frequency, urgency or suprapubic pain, or fever with flank pain. Not for pregnancy or children.
All Pathways
Internal MedicineManagement
Urinary Tract Infection Management
Urinary Tract Infection Management: Suspected UTI in a non-pregnant adult → First: pregnant, child, or no urinary symptoms? → Sepsis or septic shock? → ...
Pathway Overview
19 steps
Algorithm Steps
19 total
01Start 02Warning First: pregnant, child, or no urinary symptoms?
This pathway is for non-pregnant adults with urinary symptoms.
- Pregnant, or a child: this pathway does not apply. Use a pregnancy or paediatric UTI pathway.
- Positive urine test but no urinary symptoms (asymptomatic bacteriuria): do not treat. Exception: before a urological procedure with mucosal trauma.
- Older adult with delirium or a fall, but no urinary symptoms, fever or unstable vital signs: look for other causes; do not treat the urine result alone.
03Decision Sepsis or septic shock?
Suspect sepsis with low BP, new confusion, fast breathing, rigors, high lactate or new organ dysfunction (qSOFA, SIRS or local sepsis tool).
- If Yes
- Sepsis
04Action Sepsis from a urinary source: IV antibiotics within 1 hour
Start the sepsis pathway now. Check allergy first. Do not delay antibiotics for imaging or drainage.
- Blood cultures x2 and urine culture before the first dose, if this causes no delay
- Penicillin allergy: do not give amoxicillin. Give gentamicin and seek expert advice before any beta-lactam
- Empiric IV: 3rd- or 4th-generation cephalosporin, piperacillin-tazobactam, a carbapenem or a fluoroquinolone. Avoid a drug that a previous urine isolate was resistant to
- Carbapenem (for example meropenem 1 g IV 8-hourly) if ESBL or multidrug-resistant risk (previous resistant isolate, recent broad-spectrum antibiotics) or high local resistance to the other agents
- Australia: gentamicin IV (dose: see local gentamicin guideline; caution in myasthenia gravis) plus amoxicillin 2 g IV 6-hourly; ceftriaxone 1 g IV daily (12-hourly if critically ill) if gentamicin is unsuitable
- Urgent ultrasound or CT for obstruction or abscess
- Infected obstructed kidney: call urology now for urgent decompression (ureteric stent or nephrostomy)
05Action Admit (sepsis, vomiting, obstruction or failed oral therapy): IV antibiotics
Check allergy and kidney function first. Narrow to culture results. Switch to oral when improving and able to take oral drugs.
- No sepsis: ceftriaxone 1-2 g IV daily, piperacillin-tazobactam 4.5 g IV 8-hourly, or a fluoroquinolone (not if used in the past 12 months or in myasthenia gravis; risk of tendon rupture, aortic aneurysm, QT prolongation)
- ESBL or multidrug-resistant risk: a carbapenem such as meropenem 1 g IV 8-hourly. Sepsis: choose as in the sepsis step
- Australia: gentamicin IV (dose: see local gentamicin guideline) plus amoxicillin 2 g IV 6-hourly. No repeat gentamicin if CrCl below 40 mL/min; stop empirical gentamicin by 48 h; caution in myasthenia gravis
- Penicillin allergy: no amoxicillin; seek expert advice before a beta-lactam if the reaction was severe
- If improving: total 5-7 days of a fluoroquinolone or 7 days of another agent; 7 days also for Gram-negative bacteraemia
06Decision Improving within 48-72 hours?
Review symptoms, fever and culture results.
- If Yes
- Improving
07Outcome Improving: finish the planned course
No routine urine culture after treatment. Symptoms persist or recur within 2-4 weeks: repeat culture and change drug.
- Symptoms persist, or recur within 2-4 weeks: repeat urine culture and choose a different drug
- Recurrent UTI: use a recurrent UTI plan
If No- Not improving
08Warning Not improving at 48-72 h: look for resistance or a complication
Bladder symptoms only: repeat culture and change drug. Fever, flank pain, sepsis or a man with retention: treat as complicated and image.
- Repeat urine culture; change antibiotic to match susceptibility
- CT (or ultrasound) for obstruction, renal or perinephric abscess, or prostatic abscess
- Obstruction or abscess: urgent urology or drainage; seek infectious diseases advice for resistant organisms
09Outcome Escalate: admit, drain the source, or get specialist care
Urology for obstruction or abscess; infectious diseases for resistant organisms; ICU review if sepsis worsens.
If No- No sepsis
10Decision Where is the infection?
Cystitis: bladder only, no fever. Pyelonephritis: fever or flank pain. Complicated: catheter, urological abnormality or fever in a man (IDSA 2025).
- Cystitis: bladder symptoms only; no fever, flank pain or systemic signs (women or men)
- Pyelonephritis: fever, flank pain or costovertebral angle tenderness; no catheter or known urological abnormality
- Complicated: urinary catheter or stent, known urological abnormality, recent urological procedure, or fever in a man
- Cystitis
11Action Cystitis (bladder only, no fever): short oral course
Women with typical symptoms and no vaginal discharge can be treated without a culture.
- Urine culture if: atypical symptoms, a man, high risk of resistant organisms, or symptoms that persist or recur within 4 weeks
- Vaginal discharge or irritation: consider vaginitis or an STI
- Check previous urine culture results before you choose the drug
- Australia: mild symptoms in a non-pregnant woman under 65 who is not immunocompromised: a trial of ibuprofen without antibiotics can be considered (Therapeutic Guidelines 2025)
12Warning Before you choose: kidney function and interacting drugs
Check eGFR, allergy and current medicines.
- Nitrofurantoin and fosfomycin treat the bladder only: never use them for fever, flank pain or sepsis
- Nitrofurantoin: contraindicated if eGFR below 45 mL/min (Australian PI), in G6PD deficiency, and near term
- Trimethoprim (alone or with sulfamethoxazole): high potassium with ACE inhibitor, ARB, spironolactone or kidney impairment; raises INR with warfarin; pancytopenia with methotrexate
13Action Cystitis antibiotics: choose by local resistance
Women: 3-5 days as below. Men: 7 days.
- Nitrofurantoin modified release (monohydrate/macrocrystals) 100 mg orally twice daily for 5 days (US, EU)
- Australia: nitrofurantoin macrocrystal capsules 100 mg orally 6-hourly for 5 days (modified release not available)
- Trimethoprim-sulfamethoxazole 160/800 mg orally twice daily for 3 days, only if local resistance is 20% or less
- Australia: trimethoprim 300 mg orally once daily for 3 days
- Australia: cefalexin and fosfomycin are also first-line (Therapeutic Guidelines 2025); cefalexin dose per Therapeutic Guidelines: Antibiotic
- Women: fosfomycin 3 g orally, single dose (slightly less effective; not if CrCl below 10 mL/min)
- Men: trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days; nitrofurantoin only if the prostate is not involved
- Keep fluoroquinolones for when no other agent can be used; do not use amoxicillin alone without culture results
- Path rejoins step 06Shared downstream outcome
- Pyelonephritis
14Action Pyelonephritis: urine culture for all
Fever, flank pain or costovertebral angle tenderness. Check kidney function and allergy.
- Urine culture and susceptibility before the first dose
- Avoid a drug that a previous urine isolate was resistant to
- Avoid a fluoroquinolone if the patient took one in the past 12 months
- Blood cultures if admitted or severely ill
15Warning Infected obstructed kidney? Urological emergency
Suspect with a stone, known obstruction or hydronephrosis, single kidney, anuria, or sepsis.
- Urgent ultrasound; CT if hydronephrosis, suspected obstruction or severe illness
- Obstruction with infection: urgent decompression by ureteric stent or nephrostomy; call urology now
- Start antibiotics now; do not wait for imaging or drainage
16Decision Safe to treat at home?
Yes only if: no sepsis, no obstruction, not immunocompromised (including transplant or neutropenia), no severe comorbidity or frailty, can take oral drugs and fluids, and review in 48-72 hours is possible. Otherwise admit.
- If Yes
- Home
17Action Home treatment (no sepsis, no obstruction): oral antibiotics, review in 48-72 h
Not for immunocompromised patients. Choose by previous cultures and local resistance. If improving: 5-7 days of a fluoroquinolone or 7 days of another agent.
- Ciprofloxacin 500 mg orally twice daily for 7 days, if local fluoroquinolone resistance is 10% or less
- Levofloxacin 750 mg orally once daily for 5 days (not available in Australia)
- Trimethoprim-sulfamethoxazole 160/800 mg orally twice daily for 7 days, only if the organism is susceptible (check potassium and INR risks)
- Resistance uncertain, or oral beta-lactam or trimethoprim-sulfamethoxazole started before culture: give ceftriaxone 1 g IV once first
- Fluoroquinolone harms: tendon rupture (older age, corticosteroids), aortic aneurysm, QT prolongation, low or high glucose, neuropathy; avoid in myasthenia gravis; raises INR with warfarin
- Australia: fluoroquinolones are restricted to organisms resistant to other agents; choose the oral agent per Therapeutic Guidelines: Antibiotic
- Path rejoins step 06Shared downstream outcome
If No- Admit
- Path rejoins step 05Shared downstream outcome
- Complicated
18Action Complicated UTI (catheter, abnormal tract or febrile man): culture first
Infection beyond the bladder or with a urinary device.
- Urine culture before antibiotics; blood cultures if febrile
- Look for obstruction, retention or abscess (see next step)
- Refer to urology: stones, obstruction, stent, nephrostomy or recent urological surgery
19Action Complicated UTI: treat the cause as well as the infection
Antibiotics alone may fail if a device or obstruction remains.
- Catheter no longer needed: remove it and culture a midstream urine. Still needed and in place 2 weeks or more: replace it and culture from the new catheter
- Man with fever or pelvic or perineal pain: consider acute prostatitis; 10-14 days may be needed
- Kidney transplant or immunocompromised: seek specialist advice
- Then choose home or hospital treatment as for pyelonephritis
- Path rejoins step 15Shared downstream outcome
Guideline Source
IDSA 2025 Guidelines on Management and Treatment of Complicated Urinary Tract Infections (with IDSA/ESCMID 2010 update on acute uncomplicated cystitis, CID 2011)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Not for pregnancy or children; asymptomatic bacteriuria is not treated except before urological procedures with mucosal trauma.
- Empiric choices depend on local resistance and previous cultures; in Australia follow Therapeutic Guidelines: Antibiotic.
- Catheter-associated UTI, prostatitis, kidney transplant and immunocompromise are covered only in outline; seek specialist advice.
- Gentamicin dosing is not given; use the local aminoglycoside guideline.
Contraindicated Populations
pregnancychildren
Applicable Regions
USEUAU
AU: Therapeutic Guidelines: Antibiotic (2025 update): cystitis first line trimethoprim 300 mg daily for 3 days, nitrofurantoin 100 mg 6-hourly for 5 days (macrocrystal capsules only), cefalexin or fosfomycin; ibuprofen trial an option for mild symptoms in women under 65. Fluoroquinolones restricted; levofloxacin not available. Urosepsis: gentamicin plus amoxicillin 2 g IV 6-hourly (Victorian Adult Sepsis Pathway 2025).
EU: EAU Urological Infections guideline: first-line cystitis agents are fosfomycin, pivmecillinam, nitrofurantoin or nitroxoline; fluoroquinolones restricted by the European Commission (2019).
US: IDSA 2025 complicated UTI guideline (selection, IV-to-oral switch, duration); IDSA/ESCMID 2011 for uncomplicated cystitis.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Urinary Tract Infection Management?
The Urinary Tract Infection Management is a management clinical algorithm for Internal Medicine. It provides a structured decision tree to guide clinical decision-making, based on IDSA 2025 Guidelines on Management and Treatment of Complicated Urinary Tract Infections (with IDSA/ESCMID 2010 update on acute uncomplicated cystitis, CID 2011).
What guideline is the Urinary Tract Infection Management based on?
This algorithm is based on IDSA 2025 Guidelines on Management and Treatment of Complicated Urinary Tract Infections (with IDSA/ESCMID 2010 update on acute uncomplicated cystitis, CID 2011) (DOI: 10.1093/cid/ciaf460).
What are the limitations of the Urinary Tract Infection Management?
Known limitations include: Not for pregnancy or children; asymptomatic bacteriuria is not treated except before urological procedures with mucosal trauma.; Empiric choices depend on local resistance and previous cultures; in Australia follow Therapeutic Guidelines: Antibiotic.; Catheter-associated UTI, prostatitis, kidney transplant and immunocompromise are covered only in outline; seek specialist advice.; Gentamicin dosing is not given; use the local aminoglycoside guideline.. Individual patient factors may require deviation from these recommendations.
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