Treatment Guideline Chart
Complicated urinary tract infection (UTI) is associated with a condition [eg structural or functional abnormalities of the genitourinary tract (GUT)] or the presence of an underlying disease that interferes with host defense mechanisms, which increases the risks of acquiring infection, failing therapy or having recurrent infections. The successful treatment of a complicated UTI considers effective antimicrobial therapy, optimal management of the underlying abnormalities or other diseases and adequate life-supporting measures.

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  • Specific questioning for the presence or absence of prior urinary infections and therapy, genitourinary surgeries, nephrolithiasis, gross hematuria, sickle cell disease and other associated disease predispositions

Laboratory Tests

  • Urine analysis with microscopic exam, urine culture and sensitivity testing should be performed before, during and after therapy
  • A pregnancy test may be done in women of reproductive age

Significant Bacteriuria

  • Women: ≥105 colony forming units (cfu)/mL in midstream urine (MSU) sample or >104 cfu/mL in straight catheter urine sample
  • Asymptomatic patients: 2 consecutive urine samples showing ≥105 cfu/mL taken at least 24 hours apart with the same bacterial species


  • ≥10 WBC/mm3, though may not be present with an obstructed urinary collecting system
  • Pyuria is not diagnostic for catheter-associated UTI in catheterized patients

Urine Dipstick

  • For routine assessment including leukocyte esterase test, hemoglobin and nitrite reaction

Urine Culture and Sensitivity 

  • Urine specimen for culture should be obtained prior to the administration of antibiotics
    • Urine culture is obtained in catheterized patients after the catheter has been removed 
    • Selection of antibiotic should be re-evaluated once culture results become available
  • If possible, to avoid the emergence of resistant strains, therapy should be guided by urine culture


Further Work-up to Identify and Correct Anatomical, Functional or Metabolic Abnormality

  • Radiologic studies are indicated to find the cause of complicated UTI
  • Imaging of the urinary tract should be undertaken to evaluate for hydronephrosis, stone disease and urinary tract abnormalities
    • Plain abdominal radiographs may be useful to evaluate for abnormal calcifications, renal contour and gas patterns
    • Intravenous (IV) pyelogram for radiographic images of the bladder, kidneys and ureters to determine extent of urinary obstruction
    • Voiding cystourethrogram for evaluation of the neurogenic bladder and urethral diverticulum, and to determine the presence of vesicoureteral reflux
    • Renal ultrasonography is an extremely valuable tool to evaluate for hydronephrosis, pyonephrosis and perirenal abscesses
    • Computed tomography (CT) scan is more sensitive for nephrolithiasis, defining renal and suprarenal pathology
    • Cystoscopy for a convenient inspection of the urethra and the bladder
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