Drugs & Aging

, Volume 18, Issue 4, pp 243–254 | Cite as

A Practical Guide to Antimicrobial Management of Complicated Urinary Tract Infection

  • Lindsay E. NicolleEmail author
Therapy in Practice


Complicated urinary tract infection occurs in the setting of a functionally or structurally abnormal genitourinary tract. Many different abnormalities may lead to a designation of complicated urinary tract infection, and these abnormalities will have different influences on the frequency of infection and likelihood of relapse or reinfection. The microbiology of complicated urinary tract infection is characterised by a greater variety of organisms and increased likelihood of antimicrobial resistance compared with acute uncomplicated urinary tract infection.

Appropriate management requires a urine specimen for culture prior to institution of antimicrobial therapy, and ensuring that the underlying abnormality is fully characterised to determine whether it can be corrected. A wide variety of antimicrobial agents are effective for treatment, and are usually given for 7 to 14 days. If the underlying abnormality can be corrected, subsequent infections may be prevented. However, if the underlying abnormality cannot be corrected a high recurrence rate of infection, approaching 50% by 4 to 6 weeks, is expected. Further study of complicated urinary tract infection is necessary, including determination of when asymptomatic bacteriuria warrants treatment, and exploration of nonantimicrobial approaches to management.


Urinary Tract Infection Antimicrobial Therapy Bacteriuria Neurogenic Bladder Genitourinary Tract 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Nicolle LE. A practical guide to the management of complicated urinary tract infection. Drugs 1997; 53: 583–92PubMedCrossRefGoogle Scholar
  2. 2.
    Ramsey JWA, Garnham AJ, Mulhall AB, et al. Biofilms, bacteria, and bladder catheters: a clinical study. Br J Urol 1984; 64: 395–8CrossRefGoogle Scholar
  3. 3.
    Nicolle LE. Asymptomatic bacteriuria in the elderly. Infect Dis North Am 1997; 11: 647–67CrossRefGoogle Scholar
  4. 4.
    Raz R, Gennesin Y, Wesser J, et al. Recurrent urinary tract infections in postmenopausal women. Clin Infect Dis 2000; 30: 152–6PubMedCrossRefGoogle Scholar
  5. 5.
    Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am 1997; 11: 609–22PubMedCrossRefGoogle Scholar
  6. 6.
    Waites KB, Canupp KC, DeVivo MJ. Epidemiology and risk factors for urinary tract infection following spinal cord injury. Arch Phys Med Rehab 1993; 74: 691–5CrossRefGoogle Scholar
  7. 7.
    Larsen EH, Gusser TC, Madsen PO. Antimicrobial prophylaxis in urologic surgery. Urol Clin North Am 1986; 13: 591–604PubMedGoogle Scholar
  8. 8.
    Charton M, Vallencien G, Veillon B, et al. Use of antibiotics in conjunction with extracorporeal lithotripsy. Eur Urol 1990; 17: 134–8PubMedGoogle Scholar
  9. 9.
    Darouiche RD, Smith MS, Markowski J. Antibiotic prophylaxis for urodynamic resting in patients with spinal cord injury: a preliminary study. J Hosp Infect 1994; 28: 57–61PubMedCrossRefGoogle Scholar
  10. 10.
    Damron DJ, Warren JW, Chippendale GR, et al. Do clinical microbiology laboratories report complete bacteriology in urine from patients with long term urinary catheters? J Clin Microbiol 1986; 24: 400–4PubMedGoogle Scholar
  11. 11.
    Waites KB, Canupp KC, DeVivo MJ. Efficacy and tolerance of norfloxacin in treatment of complicated urinary tract infection in outpatients with neurogenic bladder secondary to spinal cord injury. Urology 1991; 38: 589–96PubMedCrossRefGoogle Scholar
  12. 12.
    Nicolle LE, Louie TJ, Dubois J, et al. Treatment of complicated urinary tract infections with lomefloxacin compared with trimethoprim/sulfamethoxazole. Antimicrob Agents Chemother 1994; 38: 1368–73PubMedCrossRefGoogle Scholar
  13. 13.
    Cox CE, Holloway WJ, Geckler RW. Amulticenter comparative study of meropenem and imipenem/cilastatin in the treatment of complicated urinary tract infections in hospitalized patients. Clin Infect Dis 1995; 21: 86–92PubMedCrossRefGoogle Scholar
  14. 14.
    Kauffman CA, Vazquez JA, Sobel JD, et al. Prospective, multicenter surveillance study of funguria in hospitalized patients. The National Institute for Allergy and Infectious Diseases (NIAID) Mycose Study Group Clin. Infect Dis 2000; 30: 14–8CrossRefGoogle Scholar
  15. 15.
    Nicolle LE. Urinary tract pathogens in complicated infection and in elderly individuals. J Infect Dis 2001; Mar 1; 183Suppl. 1: S5–8PubMedCrossRefGoogle Scholar
  16. 16.
    Cardenas DD, Hooton TM. Urinary tract infection in persons with spinal cord injury. Arch Phys Med Rehab 1995; 76: 272–80CrossRefGoogle Scholar
  17. 17.
    Rodgers K, Nocolle LE, McIntyre M, et al. Pyuria in institutionalized elderly subjects. Can J Infect Dis 1991; 2: 142–6PubMedGoogle Scholar
  18. 18.
    Rubin RH, Shapiro ED, Andriole VT, et al. Evaluation of new anti-infective drugs for treatment of urinary tract infection. Clin Infect Dis 1992; 15Suppl. 1: S216–27PubMedCrossRefGoogle Scholar
  19. 19.
    Cafferky MT, Falkiner FR, Gillespie WA, et al. Antibiotic for the prevention of septicaemia in urology. J Antimicrob Chemother 1982; 9: 471–7CrossRefGoogle Scholar
  20. 20.
    Patterson TF, Andriole VT. Detection, significance, and therapy of bacteriuria in pregnancy: update in the managed health care era. Infect Dis Clinics North Am 1997; 11: 593–603CrossRefGoogle Scholar
  21. 21.
    Hansson S, Jodal U, Lincoln K, et al. Untreated asymptomatic bacteriuria in girls: II. Effect of phenoxymethylpenicllin and erythromycin given for intercurrent infections. BMJ 1989; 298: 856–9PubMedCrossRefGoogle Scholar
  22. 22.
    Dow G, Thompson M, Harding G, et al. A double-blind randomized comparison of three versus fourteen days of ciprofloxacin in spinal cord injured patients with acute symptomatic urinary tract infection [abstract 584]. Clin Infect Dis 1997; 25: 463Google Scholar
  23. 23.
    Smith JW, Jones SR, Reed WP, et al. Recurrent urinary tract infections in men: characteristics and response to therapy. Ann Intern Med 1979; 91: 544–8PubMedGoogle Scholar
  24. 24.
    Gleckman R, Crowley M, Natsias GA. Recurrent urinary tract infections in men: an assessment of contemporary treatment. Am J Med Sci 1980; 279: 31–6PubMedCrossRefGoogle Scholar
  25. 25.
    Gribble MJ, Puterman ML. Prophylaxis of urinary tract infection in persons with recent spinal cord injury: a prospective, randomized, double-blind, placebo controlled study of trimethoprim/sulfamethoxazole. Am J Med 1993; 95: 141–52PubMedCrossRefGoogle Scholar
  26. 26.
    Sheehan GJ, Harding GKM, Haase DA, et al. Double-blind, randomized comparison of 24 weeks of norfloxacin followed by 12 weeks of placebo in the therapy of complicated urinary tract infection. Antimicrob Agents Chemother 1988; 32: 1292–3PubMedCrossRefGoogle Scholar
  27. 27.
    Chinn RH, Maskell R, Mead JA, et al. Renal stones and urinary infection: a study of antibiotic treatment. BMJ 1976; 2: 1411–3PubMedCrossRefGoogle Scholar
  28. 28.
    Fang G, Brennen C, Wagener M, et al. Use of ciprofloxacin versus use of aminoglycosides for therapy of complicated urinary tract infection: prospective, randomized, clinical and pharmacokinetic study. Antimicrob Agents Chemother 1991; 35: 1849–55PubMedCrossRefGoogle Scholar
  29. 29.
    Hoepelman IM, Havinga WH, Benne RA, et al. Safety and efficacy of lomefloxacin versus norfloxacin in the treatment of complicated urinary tract infections. Eur J Clin Microbiol Infect Dis 1993; 12: 343–7PubMedCrossRefGoogle Scholar
  30. 30.
    Nicolle LE, Mayhew WJ, Bryan L. Outcome following antimicrobial therapy for asymptomatic bacteriuria in elderly women resident in an institution. Age Aging 1988; 17: 187–92CrossRefGoogle Scholar
  31. 31.
    Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic. Arch Intern Med 2000; 160: 678–82PubMedCrossRefGoogle Scholar
  32. 32.
    Orr P, Nicolle LE, Duckworth H, et al. Febrile urinary infection in the institutionalized elderly. Am J Med 1996; 100: 71–7PubMedCrossRefGoogle Scholar
  33. 33.
    Kunin CM, Douthitt S, Dancing J, et al. The association between the use of urinary catheters and morbidity and mortality among elderly patients in nursing homes. Am J Epidemiol 1992; 135: 291–301PubMedGoogle Scholar
  34. 34.
    Raz R, Schiller D, Nicolle LE. Chronic indwelling catheter replacement prior to antimicrobial therapy for symptomatic urinary infection. J Urol 2000; 164: 1254–8PubMedCrossRefGoogle Scholar
  35. 35.
    Nicolle LE. The measurement and significance of antibiotic activity in the urine. In: Lorian J, editor Antibiotics in laboratory medicine. 4th ed. Baltimore (MD): Williams and Wilkins, 1996: P793–812Google Scholar
  36. 36.
    Zhanel G, Harding GKM, Nicolle LE. Asymptomatic bacteriuria in diabetics. Rev Infect Dis 1991; 13: 150–4PubMedCrossRefGoogle Scholar
  37. 37.
    Nicolle LE. Asymptomatic bacteriuria in diabetic women. Diabetes Care 2000; 23: 722–3PubMedCrossRefGoogle Scholar
  38. 38.
    Sobel JD, Kauffman CA, McKinsey D, et al. Candiduria: a randomized, double-blind study of treatment with fluconazole and placebo. The National Institute for Allergy and Infectious Diseases (NIAID) Mycose Study Group. Clin Dis 2000; 30: 19–24CrossRefGoogle Scholar
  39. 39.
    Leu HS, Huang CT. Clearance of funguria with short course antifungal regimens: a prospective, randomized controlled study. Clin Infect Dis 1995; 20: 1152–7PubMedCrossRefGoogle Scholar
  40. 40.
    Jacobs LG, Skidmore EA, Freeman K, et al. Oral fluconazole compared with amphotericin B bladder irrigation for fungal urinary tract infection in the elderly. Clin Infect Dis 1996; 22: 30–5PubMedCrossRefGoogle Scholar
  41. 41.
    Fan-Havard P, O’Donovan C, Smith SM, et al. Oral fluconazole versus amphotericin B bladder irrigation for treatment of candidal funguria. Clin Infect Dis 1995; 21: 960–5PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 2001

Authors and Affiliations

  1. 1.Department of Internal MedicineUniversity of Manitoba, Health Sciences CentreWinnipegCanada

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