The Infectious Diseases Society of America (IDSA) recently released its first guidelines for the treatment and management of complicated urinary tract infections (cUTIs). Previously, IDSA generated guidelines focused on uncomplicated cystitis and pyelonephritis in women. As more data emerged, the IDSA recognized the need for cUTI guidelines for women and men. These new guidelines cover UTI classifications, antibiotic selection recommendations, antibiotic duration recommendations, and more. 

For your convenience we’ve outlined some key highlights below. For more information regarding these new guidelines you can click here to view our summary, or click here to view the full text. 

Key Elements of the IDSA Guidelines:
  • New Classifications of Uncomplicated UTI (uUTI) and cUTI:
    • The new classification of uUTI now includes men; defined as an infection confined to the bladder. 
    • An updated definition of cUTI now includes men; defined as infection beyond the bladder.
  • Initial Selection Among Empiric Antibiotic Options for cUTI:
    • For patients with sepsis due to complicated UTI, we suggest initially selecting among the following antibiotics, using the four-step assessment (Figure 1.1): third- or fourth-generation cephalosporins, carbapenems, piperacillin-tazobactam, or fluoroquinolones, rather than newer agents (novel beta lactam-beta lactamase inhibitors, cefiderocol, plazomicin) or older aminoglycosides.
    • For patients with suspected complicated UTI without sepsis, we suggest initially selecting among the following antibiotics, using the four-step assessment (Figure 1.1): third- or fourth-generation cephalosporins, piperacillin-tazobactam, or fluoroquinolones, rather than carbapenems and newer agents (novel beta lactam-beta lactamase inhibitors, cefiderocol, plazomicin) or older aminoglycosides.
  • Process to Guide Empiric Antibiotic Choice for cUTI:
    • For patients with suspected complicated UTI (including pyelonephritis), we suggest that the selection of empiric antibiotic therapy be initially guided by the severity of illness, specifically by whether the patient is in sepsis or not.
    • In patients with complicated UTI (including acute pyelonephritis), we suggest avoiding antibiotics to which the patient has had a resistant pathogen isolated from the urine previously.
    • In patients suspected of cUTI, empiric antibiotic therapy selection should account for patient-specific considerations (e.g. risk of allergic reaction, contraindications, or drug-drug interactions) to avoid preventable adverse events.
    • In patients with sepsis assumed to be caused by complicated UTI (including acute pyelonephritis), we suggest using an antibiogram to further tailor empiric antibiotic choice only if the antibiogram is local, recent, and relevant to the patient.
  • Selection of Definitive Antibiotic Therapy for cUTI:
    • In patients with confirmed complicated UTI, we suggest selecting a definitive effective antibiotic with a targeted spectrum based on the results of urine culture (identification and susceptibility) as soon as these are available, rather than continuing empiric broad-spectrum antibiotics for the complete duration of treatment.
  • Recommendations on the Timing of Intravenous to Oral Antibiotics Transition for cUTI:
    • In patients with complicated UTI (including acute pyelonephritis) treated initially with parenteral therapy who are clinically improving, able to take oral medication, and for whom an effective oral option is available, we suggest transitioning to oral antibiotics rather than continuing parenteral therapy for the remaining treatment duration.
  • Recommendations on the Duration of Antibiotics for Complicated UTI:
    • In patients presenting with complicated UTI (including acute pyelonephritis) and who are improving clinically on effective therapy, we suggest treating with a shorter course of antimicrobials, using either 5-7 days of a fluoroquinolone (conditional recommendation, moderate certainty of evidence) or 7 days of a non-fluoroquinolone antibiotic.
    • In patients presenting with complicated UTI with associated Gram-negative bacteremia and who are improving clinically on effective therapy, we suggest treating with a shorter course (7 days) of antimicrobial therapy rather than a longer course (14 days).

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