[1]

Table of Content
TOPIC PAGE NO.
Urinary tract infection 3
(UTI)

Prostatitis 10

Epididymitis 12

Fournier gangrene 13

Renal and prenephric 14

abcess
Surgical prophylaxis 15

Surgical site infection 17

(SSIs)

[2]
Urinary tract infection (UTI)

Acute simple Acute complicated UTІ

cystitis (ԁysսriа, urinary urgency, Руеlοոерhritiѕ
➢ is confined to the and/or urinary frequency)
along with Flank pain and/or
bladder; typical costovertebral angle
symptoms include: ✓ fever (>37.7ºC) tenderness in the setting of
✓ Dysuria ✓ other signs or pyuria and bаϲteriuriа
symptoms of as
✓ Urinary frequency
chills, rigors, or acute Fever and typical symptoms
✓ Urinary urgency mental status of cystitis are usually
✓ Suprapubic pain changes.
present, but their absence
➢ There are no signs or
In such cases, pyuria and does not rule out the
symptoms that bасtеriսria support the diagnosis.
suggest an upper diagnosis.
tract or systemic
The diagnosis of acute
infection. complicated UТΙ is unlikely if
руսriа is absent.

[3]
 1) Acute simple cystitis
Oral antimicrobial options for acute simple cystitis

First-line options
Antimicrobial Dose Duration Comment
Nitrofurantoin 100 mg orally twice Females: 5 days Retains activity against
some MDR organisms
daily Males: 7 days Avoid if:
✓ Concern for early
pyelonephritis
✓ CrCl <30
mL/minute

Trimethoprim- One double- Females: 3 days Useful for males with

concern for possible
sulfamethoxazole strength tablet Males: 7 days prostatitis
(160 mg/800 mg) Avoid if:
orally twice daily Regional prevalence of
resistance known to be
>20%

Fosfomycin 3 g of powder Single dose Retains activity against

some MDR organisms
mixed in water and Avoid if:
administered orally Concern for early
pyelonephritis

[4]
Alternatives: Other beta-lactams
(presence of any reason to avoid the previous options)

Antimicrobial Dose Duration Comment

Amoxicillin-clavulanate 500 mg orally twice Females: 5 to 7 days Dose is based on
daily Males: 7 days amoxicillin
component

Cefadroxil 500 mg orally twice Females: 5 to 7 days

daily Males: 7 days
Cefpodoxime 500 mg orally twice Females: 5 to 7 days
daily Males: 7 days

Alternatives: fluoroquinolones
(presence of an allergy to beta lactams)

Antimicrobial Dose Duration Comment

Ciprofloxacin 250 mg orally twice Females: 3 days Useful for males
daily Males: 5 days with concern for
possible prostatitis

Levofloxacin 250 mg orally once Females: 3 days Useful for males

daily Males: 5 days with concern for
possible prostatitis

For each group of antibiotic options presented, the choice among them depends on

✓ patient circumstances (allergy, tolerability, and adherence)

✓ susceptibility of prior urinary isolates
✓ local community resistance
✓ prevalence
✓ availability
✓ cost

[5]

and
 Trimethoprim 100 mg orally twice daily for 3 days is a potential option for individuals who
have a sulphonamide (but not trimethoprim) allergy if regional prevalence of resistance is
known to be <20%.

For females with

✓ Urinary tract abnormalities, For males
✓ Immunocompromising
conditions who have more severe cystitis
✓ Poorly controlled diabetes symptoms or concern about early
mellitus involvement of the prostate (e.g.,
recurrent UTI with the same pathogen,
It is reasonable to use a longer duration equivocal prostatic tenderness),
of therapy (e.g., 7 days).
use higher doses of fluoroquinolones
If a longer duration of Fosfomycin is (ciprofloxacin 500 mg orally twice daily
needed (i.e., more than a single dose), or 1000 mg extended release once daily,
additional doses are administered or levofloxacin 750 mg orally once daily).
every 2 to 3 days for up to 3 doses.

Suspect multidrug-resistant gram-negative urinary tract infection in

patients with a history of any of the following in the prior 3 months:
✓ A multidrug-resistant gram-negative urinary isolate or a fluoroquinolone-
resistant Pseudomonas aeruginosa isolate
✓ Inpatient stay at a health care facility (e.g., hospital, nursing home, long-term
acute care facility)
✓ Use of a fluoroquinolone, trimethoprim-sulfamethoxazole, or broad-
spectrum beta-lactam (e.g., third or later generation cephalosporin)

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 2) Pyelonephritis

N.B The presence of bаϲtеriսriа (≥105 colony-forming units/mL of a uropathogen) with or without
руսriа in the absence of any symptom that could be attributable to a UТΙ is called asymptomatic
bаϲteriuria and generally does not warrant treatment in nonpregnant patients who are not
undergoing urologic surgery.

urine analysis and culture preferred before starting antibiotics.

Positive urine culture of 105 CFU/ ml or more of no more than 2 species

Empirical antibiotics

Critical illness and/or urinary tract obstruction

(with severe sepsis or otherwise warranting intensive care unit admission), getting worse on
current therapy.

in regions where community prevalence of ESBL-producing organisms is high or uncertain

✓ Imipenem or Meropenem

plus

✓ Vancomycin , Teicoplanin or Linezolid.

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Other hospitalized pateints not critically ill
1) Risk factors for MDR gram negative urinary tract infection
✓ piperacillin-tazobactam
✓ cefepime not for ESBL risk or history of infection with ESBL
✓ imipenem or meropenem

if previous urinary isolates or other risk factors for MRSA

add vancomycin , teicoplanin or linezolid

2) No risk factors for infection with a multidrug-resistant gram-negative organism

✓ ceftriaxone or
✓ ciprofloxacin or levofloxacin

if previous urinary isolates or other risk factors for MRSA

add vancomycin , teicoplanin or linezolid

If there is a risk of P. aeruginosa (prior urinary isolates or febrile neutropenia),

piperacillin-tazobactam, cefepime, or a fluoroquinolone

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Duration
✓ flսοrοԛսiոοlοnеs for 5 to 7 days
✓ trimethoprim-sulfamethoxazole for 7 to 10 days
✓ beta-lactams for 7 to 10 days
✓ 5 to 10 days for patient with symptomatic improvement (within the first
48 to 72 hours of therapy).
✓ Longer antibiotic durations for patient with no symptomatic
improvement (within the first 48 to 72 hours of therapy) or a
nonobstructing stone that cannot be removed.

[9]
 Prostatitis

1) Acute prostatitis in hospitalized patients

For patients with acute рroѕtаtitiѕ who can take oral medications:

a) fluoroquinolone ( ciprofloxacin 500 mg orally every 12 hours or levofloxacin 500 mg

orally once daily)

b) Trimethoprim-sulfamethoxazole (one double-strength tab orally every 12 hours)

For patients with acute bacterial prostatitis who need parenteral antibiotic therapy if
they cannot tolerate oral medication, demonstrate signs of severe sepsis, or have
bacteremia: -

1- Intravenous levofloxacin or ciprofloxacin may be given with or without an

аmiոοglуϲοsidе (gentamicin or tobramycin 5mg/kg daily, if the creatinine clearance
is normal)

2- intravenous beta-lactam with activity against Enterobacteriaceae with or without an

аmiոοglуϲоside is an alternate initial regimen.

3- Empiric treatment with an intravenous carbapenem or broad-spectrum реոiϲillin or

ϲерhаlοѕрoriո (with or without gentamicin) pending culture and sensitivity data is
appropriate for patients who develop nosocomial prostatitis (e.g, following a
procedure for which they received a prophylactic fluoroquinolone) or who have a
history of infections with drug-resistant pathogens, because of the increased risk of
infection with a ԛսiոοloոe-resistant organism.

The choice between these should take into account patient tolerance
and regional patterns of Enterobacteriaceae drug resistance.

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Duration of therapy

➢ Patients initiated on parenteral antibiotics can be switched to oral antibiotics, if

drug susceptibility and patient tolerance allow, 24 to 48 hours following
improvement in fever and clinical symptoms.
➢ We treat with antibiotics for up to six weeks to ensure eradication of the infection.
➢ For patients who have no prostatic abscess and, with treatment, have a painless
rectal examination, sterile urine, and normal inflammatory markers (erythrocyte
sedimentation rate and C-reactive protein), stopping treatment at four weeks is
reasonable.

2) Chronic prostatitis in hospitalized patients

Prolonged antibiotic therapy with:

1- A fluoroquinolone( ciprofloxacin 500 mg orally every 12 hours or levofloxacin 500 mg

orally daily, each given for four to six weeks) is the drug of choice for both initial and
recurrent episodes, if organism susceptibility and patient tolerance allow .

2- Trimethoprim-sulfamethoxazole
(one double-strength tablet) orally twice daily for three months

3- Tetracyclines (doxycylcin)

4- Macrolide (azithromycin) (500 mg daily for three days each week for three weeks)

5- Fosfomycin 3 g once daily for one week then 3 g every 48 hours for a total of 6 to 12
weeks

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 Epididymitis

Is the patient sexually active?

Yes No
Are there any of the following? Coverage for enteric pathogens:
-Obstructive uropathy Levofloxacin 500 mg orally once
- Recent urologic procedure daily for 10 days
Or
Trimethoprim-
sulfamethoxazole one
double-strength tablet orally
twice
daily for 10 days

Yes No
Ceftriaxone 500 mg Ceftriaxone 500
(1 g in patients ≥150 mg (1 g in patients
kg) IM as a single ≥150 kg) IM as a
dose single dose
plus plus
A fluoroquinolone Doxycycline 100
(Levofloxacin 500 mg orally twice
mg orally once daily daily for 10 days
for 10 days)

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 Fournier gangrene
➢ Treatment of NSTI consists of early and aggressive surgical exploration and
debridement of necrotic tissue with broad spectrum empiric antibiotic.
Administration of antibiotic in absence of debridement is associated with a mortality
rate 100%.

➢ Antibiotic therapy should be initiated after obtaining blood cultures

Piperacillin/ tazobctam
Or

Carbapenem For patient with NSTI due to beta-

hemolytic streptococci or S.aureus
a) Meropenem that are resistant to clindamycin,
b) Imipenem
Linezolid may be used as alternative
Plus therapy for vancomycin +
vancomycin clindamycin
plus
clindamycin

Patient with hypersensitivity to carbapenem or Piperacillin/ tazobactam

May be treated with aminoglycosides or fluoroquinolones plus

metronidazole

Duration

Antibiotic should be continued until no further need for debridement and hemodynamic
status has normalized for at least 2 weeks.

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 Renal and prenephric abcess
➢ Management of renal and perinephric abscess includes antimicrobial therapy in
conjunction with percutaneous drainage (when warranted).
➢ Renal or perinephric abscess are treated with IV therapy, which start as soon as blood
and urine cultures have been collected.
➢ For perinephric abscess, empiric therapy can be delayed until drainage of the abscess
can be performed, since a sample of the perinephric abscess may be the only
microbiologically informative specimen.

Vancomycin ➢ Patients with very severe

disease, such as critical
Plus one of the following: illness or septic shock, Add
levofloxacin or ciprofloxacin.
a) Piperacillin- ➢ If blood or urine cultures
suggest a gram-positive
tazobactam
organism, the vancomycin
b) Cefepime alone can be continued; if
c) Meropenem they suggest a gram-negative
d) Imipenem organism, the vancomycin
can be discontinued.

Duration:
➢ 2-3 weeks antibiotic therapy throughout and after drainage.
➢ The final duration of antibiotic therapy should be determined by the extent of
infection, the patient's clinical response to initial management, and normalization
of inflammatory markers.

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Surgical prophylaxis

[15]
 ‫يتم إعطاء جرعة واحدة من المضاد الحيوى بالوريد قبل إجراء العملية ب ‪ 60‬دقيقة و في حالة استخدام‬
‫سيبروفلوكساسين يعطى قبل العملية ب ‪ 120 – 60‬دقيقة لتفادى حدوث أي تفاعالت حساسية قرب وقت‬
‫التخدير‪.‬‬

‫إذا استغرق وقت العملية أكثر من ‪ 3‬ساعات أو حدث نزيف بكمية كبيرة سيحتاج المريض إلى جرعة إضافية‬
‫من المضاد الحيوى أثناء العملية كما هو موضح بالجدول بشرط أن تكون وظائف الكلى طبيعية‪.‬‬

‫في حالة وجود حساسية من البيتاالكتام يعطى واحد من اآلتى ‪:‬‬

‫)‪✓ Clindamycin (900 mg IV) plus gentamicin (5 mg/kg IV‬‬

‫)‪✓ Clindamycin (900 mg IV) plus ciprofloxacin (400 mg IV‬‬
‫)‪✓ Clindamycin (900 mg IV) plus levofloxacin (500 mg IV‬‬
‫)‪✓ Vancomycin (15 mg/kg IV not to exceed 2 g) plus ciprofloxacin (400 mg IV‬‬
‫)‪✓ Vancomycin (15 mg/kg IV not to exceed 2 g) plus levofloxacin (500 mg IV‬‬

‫ال يحتاج المريض إلى جرعات أخرى من المضادات الحيوية الوقائية بعد العملية ما عدا حاالت‬
‫‪ ruptured viscus‬تستكمل المضادات الحيوية لمدة ‪ 5‬أيام‬

‫في حالة حدوث عدوى بكتيرية بعد العملية يجب كتابة نوع العدوى البكتيرية وعالمات و أعراض العدوى داخل ملف‬
‫المريض و يطلب سحب مزرعة بواسطة األخصائي أو االستشاري المعالج قبل بدء المضاد الحيوي المناسب‪.‬‬

‫]‪[16‬‬
 Surgical site infections (SSIs)
Treatment
➢ Should always include suture removal plus I&D.

➢ Concomitant use of antimicrobial therapy is not usually indicated, but it can be

considered when:

✓ Erythema and induration extend more than 5 cm from the edge of the wound

✓ Temperature is higher than 38.5°C

✓ Heart rate is more than 110 beats / minute

✓ WBCs is greater than 12 × 103 cells / mm3

Empirical therapy
• First-generation cephalosporin or anti staphylococcal penicillin is appropriate in
most cases.

• If a patient has risk factor for MRSA, Vancomycin, Daptomycin or linezolid can
be used.

• For infection in which gram-negative bacteria or anaerobes are suspected

(surgery on the axilla, gastrointestinal tract, perineum, or female genital tract)

Then treatment with metronidazole plus fluoroquinolones or

cephalosporin should be used.

✓ SSIs rarely occur during the first 48 hours after surgery, and fever during that period
usually arises from noninfectious or unknown causes.
✓ SSIs that do occur in this time frame are almost always due to S. pyogenes or
Clostridium species.
✓ After 48 hours, SSI is a more common source of fever, and careful inspection of the
wound is indicated; by 4 days after surgery, a fever is equally likely to be caused by
an SSI or by another infection or other unknown sources.

[17]
Risk factors for Methicillin resistant Staphylococcus
aureus (MRSA) infection in adults:

Health care exposures during the prior 12 Patient-specific risk factors:

months
Recent hospitalization Known MRSA colonization or past
infection with MRSA

Residence in a long-term care facility Recent close contact with a person

colonized or infected with MRSA

Recent surgery HIV infection

Hemodialysis Injection drug use

Antibiotic use within prior 6 months

[18]
 TOPIC References

➢ Pyelonephritis ➢ Up To Date

➢ Prostatitis ➢ Up To Date

➢ Epididymitis ➢ Up To Date

➢ Fournier gangrene ➢ Up To Date

➢ Renal and prenephric abcess ➢ Up To Date

➢ Surgical prophylaxis ➢ Up To Date

➢ ACCP updates in therapeutics
2023

➢ Surgical site infection (SSIs) ➢ IDSA GUIDELINES for SSIs 2014

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