Uncomplicated UTI Management (IDSA 2011)

Algorithm Steps

1. ▶

   Start

   Suspected UTI

   Dysuria, frequency, urgency in adult female

   1. ◆

      Decision

      Complicated UTI Risk Factors?

      Requires different management

      • Male sex
      • Pregnancy
      • Diabetes
      • Immunosuppression
      • Urinary tract abnormality
      • Recent instrumentation
      • Symptoms >7 days
      • Recent antibiotic use
      1. ⚠

         Warning

         Complicated UTI

         Obtain culture, broader spectrum therapy

         • Urine culture before treatment
         • Fluoroquinolone or beta-lactam
         • 7-14 day course
         • Consider imaging if not improving
         • ID/urology consult if recurrent
      2. ◆

         Decision

         Pyelonephritis Symptoms?

         Upper tract involvement

         • Fever >38°C
         • Flank pain or CVA tenderness
         • Nausea/vomiting
         • Systemic symptoms
         1. ●

            Action

            Acute Pyelonephritis

            Culture required, consider admission

            • Urine culture mandatory
            • Outpatient: fluoroquinolone 7 days or TMP-SMX 14 days
            • Admit if: unable to tolerate PO, pregnant, septic, obstruction suspected
            • Consider CT if not improving 48-72h
         2. ●

            Action

            Uncomplicated Cystitis

            Healthy non-pregnant female

            • Empiric treatment appropriate
            • Culture not required if classic symptoms
            • Urinalysis supportive but not required
            • High probability if dysuria + frequency without vaginal symptoms
            1. ●

               Action

               First-Line Antibiotics

               IDSA recommended agents

               • Nitrofurantoin 100mg BID x 5 days (avoid if CrCl <30)
               • TMP-SMX 160/800mg BID x 3 days (if local resistance <20%)
               • Fosfomycin 3g single dose (less effective)
               • Avoid fluoroquinolones (FDA black box warning)
               1. ●

                  Action

                  Alternative Antibiotics

                  If allergies or resistance concerns

                  • Beta-lactams: amoxicillin-clavulanate, cefpodoxime, cefdinir
                  • Less effective than first-line options
                  • Reserve fluoroquinolones for no other option
                  • 7 days if using beta-lactam
                  1. ●

                     Action

                     Symptomatic Relief

                     Adjunctive measures

                     • Phenazopyridine 200mg TID x 2 days (urine turns orange)
                     • Hydration encouraged
                     • Symptoms should improve 24-48h
                     • Complete course even if improved
                     1. ◆

                        Decision

                        Symptoms Resolved?

                        Assess response

                        1. ✓

                           Outcome

                           Resolved

                           No further action needed, return PRN

                        2. ●

                           Action

                           Persistent Symptoms

                           Culture-directed therapy

                           • Obtain urine culture
                           • Consider STI testing
                           • Treat based on susceptibilities
                           • Consider ultrasound if recurrent
                           • Urology referral if anatomic concern
                           1. ●

                              Action

                              Recurrent UTI (≥3/year)

                              Prevention strategies

                              • Post-coital prophylaxis: TMP-SMX or nitrofurantoin
                              • Continuous prophylaxis: low-dose nightly
                              • Self-start therapy for reliable patients
                              • Cranberry products (limited evidence)
                              • Vaginal estrogen in postmenopausal women