UMEM Educational Pearls

Previous guidelines for the treatment of urinary tract infections (UTI) were published in 2010 and focused on treatment of uncomplicated cystitis and pyelonephritis in women. Due to lack of published evidence at the time, these guidelines notably omitted discussion of complicated UTI (cUTI) and UTI in men. In July 2025, the Infectious Diseases Society of America (IDSA) released new, long-awaited guidelines for the treatment of cUTI. Below are key guideline updates to consider in the treatment of patients with cUTI presenting to the emergency department:

Classification of Urinary Tract Infections

• Urinary tract infections were previously classified into 3 categories:
  • Uncomplicated UTI: Acute cystitis in afebrile, nonpregnant, premenopausal women without diabetes or urologic abnormalities
  • Acute pyelonephritis: Acute kidney infection in women otherwise meeting the definition of uncomplicated UTI
  • Complicated UTI: All other UTIs
• NEW UTI Classifications:
  • Cystitis: Infection confined to the bladder in afebrile men OR women
  • Complicated UTI: Infection beyond the bladder in men OR women. This includes pyelonephritis, febrile or bacteremic UTI, catheter-associated UTI (CAUTI), and prostatitis.

Antibiotic Selection for cUTI

• The IDSA recommends selection of antimicrobial therapy using a 4-step approach, which includes: assessment of illness severity, risk factors for resistance, patient-specific considerations, and the local antibiogram.
• Preferred agents by condition:
  • Sepsis, with or without shock: 3rd or 4th generation cephalosporins (e.g. ceftriaxone, cefepime), carbapenems (e.g. meropenem, ertapenem), piperacillin-tazobactam, fluoroquinolones (e.g. ciprofloxacin, levofloxacin)
  • Without sepsis, IV route of therapy: 3rd or 4th generation cephalosporins, piperacillin-tazobactam, fluoroquinolones
  • Without sepsis, oral route of therapy: Fluoroquinolones or trimethoprim-sulfamethoxazole

Duration of Antimicrobial Therapy for cUTI

• Previously the recommended duration of therapy for complicated UTI was 10-14 days.
• New guidelines suggest that for patients with cUTI (including pyelonephritis) who are improving clinically, a shorter course of therapy may be considered. Agent specific recommendations:
  • Fluoroquinolones: 5-7 days
  • Non-fluoroquinolone antibiotics: 7 days
• Most studies supporting this recommendation excluded patients with indwelling catheters, severe sepsis, immunocompromise, abscesses within the urinary tract, chronic kidney disease, bacterial prostatitis, complete urinary obstruction, or those undergoing urologic procedures. These patients may still require longer courses of therapy.

Bottom line: UTIs in males are no longer considered inherently complicated, treatment should be selected among preferred antimicrobials using a 4-step approach, and shorter (5-7 day) antibiotic courses may be considered for some patients with cUTI. As always, consult with your local antibiogram or pharmacist for guidance!

References

1. Infectious Diseases Society of America. Complicated Urinary Tract Infections (cUTI): Clinical Guidelines for Treatment and Management. July 17, 2025. Accessed Jan 6, 2026. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections/#.
2. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-e120. doi:10.1093/cid/ciq257.