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Complicated & Pyelonephritis

§ Not all patients with complicated UTI’s will have resistant isolates. Many patients in the community with complicated UTI’s start off with community acquired/susceptible isolates that become resistant with time

§ Outpatient complicated therapy is generally the same as uncomplicated except the higher end of dosing is generally used and therapy is for 7-10 days

§ Most frequently used, higher dose TMP/SMX DS or Quinolones x 7-10 days

Complicated catheterized and institutional patients

MRSA/MRSE	Vancomycin IV x 10-14 days
Enterococcus faecalis	Ampicillin IV 1-2 g q6-8h +/- Vancomycin (if VRE as in case of uro-sepsis)
Gram negatives	Ciprofloxacin 500-750 mg PO q12h or 400 mg IV q12h Levofloxacin 500 mg IV q24h Ceph II or Ceph III Gentamicin/Tobramicin 1.5 mg/kg q8-12h (peak 5-6 mcg/ml) Piperacillin 2-4 g q8h or zillacillin if beta-lactamase present
Pseudomonas aeruginosa	Ciprofloxacin Cetfazidime 1 g IV q8h Cefepime 1 g IV q12h Aztreonam 1 g IV q8h Gentamicin/Tobramicin if resistant as in case of uro-sepsis

Uro-sepsis

Caused by E. faecalis, VRE, enterobacteriaceae, P. aeruginosa...

E. faecalis	Ampicillin +/- Gentamicin Vancomycin +/- Gentamicin Linezolid 600 mg IV q12h
E. faecium	Same If VRE, use Linezolid and Synercid
E. coli	Pen, Cephs, Quinolones (see above)
Enterobacteriaceae	Aminoglycoside/Cipro plus one of below Cetfazidime/Cefepime/Aztreonam Piperacillin/Mezlocillin Imipenem cilastatin
P. aeruginosa	Same as Enterobacteriaceae