›1000 mg ER PO daily for 7 days
›Levofloxacin
›750 mg PO daily for 5 days
›If local fluoroquinolone resistance > 10%, initial parenteral dose then oral course
›Ceftriaxone IV 1 g once
›Gentamicin IV 5-7 mg/kg once
›Trimethoprim-sulfamethoxazole when susceptible known or likely
›TMP-SMX DS 160/800 mg PO every 12 hours for 14 days
›If susceptibility unknown, initial parenteral dose
›Ceftriaxone IV 1 g once
›Gentamicin IV 5-7 mg/kg once
›Oral beta-lactams as less effective option
›Amoxicillin-clavulanate 875/125 mg PO every 12 hours for 10-14 days
›Cefpodoxime 200 mg PO every 12 hours for 10-14 days
›If beta-lactam used, initial parenteral dose
›Ceftriaxone IV 1 g once
Antibiotics: inpatient or complicated
›Empiric IV regimens
›Community-acquired without ESBL risk
›Ceftriaxone IV 1-2 g daily
›Step-down to oral based on susceptibilities and clinical response
›Cefotaxime IV 2 g every 8 hours
›Ciprofloxacin IV 400 mg every 12 hours when appropriate
›Severe sepsis or healthcare exposure
›Piperacillin-tazobactam IV 4.5 g every 6 hours
›Extended infusion option
›4.5 g over 4 hours every 8 hours
›Cefepime IV 2 g every 8-12 hours
›Add metronidazole only if anaerobic source suspected outside urinary tract
›ESBL risk or known ESBL
›Ertapenem IV 1 g daily
›Non-critically ill without Pseudomonas concern
›Meropenem IV 1 g every 8 hours
›Critically ill or Pseudomonas concern
›Consider 2 g every 8 hours in severe sepsis depending on local practice and MIC
›Aminoglycoside strategy in select cases
›Gentamicin IV 5-7 mg/kg daily
›Therapeutic drug monitoring
›Avoid in advanced CKD when alternatives available
›De-escalation and duration
›Clinical response
›Afebrile trend by 48-72 hours expected
›Transition to oral when stable and tolerating PO
›Typical total duration
›Fluoroquinolone 5-7 days
›TMP-SMX 14 days
›Beta-lactam 10-14 days
›Bacteremia often 7-14 days depending on agent and source control
Source control and urologic interventions
›Obstructed infected system
›Urgent decompression (Class I principle in sepsis source control)
›Ureteral stent
›Percutaneous nephrostomy
›Antibiotics not sufficient without drainage when obstruction present
›Rapid deterioration risk
›Persistent bacteremia risk
›Catheter-associated infection
›Catheter management
›Replace catheter if in place > 2 weeks and still needed
›Remove if no longer indicated
›Culture technique considerations
›Sample from newly placed catheter if possible
Dosing and safety adjustments
›Renal dosing
›eGFR-based adjustments
›Beta-lactams dose interval changes
›Fluoroquinolone adjustments
›TMP-SMX adjustments
›Nephrotoxicity mitigation
›Avoid NSAIDs in AKI
›Avoid aminoglycosides when high risk
›Allergy considerations
›Beta-lactam allergy assessment
›Anaphylaxis history
›Severe cutaneous adverse reaction history
›Alternative regimens
›Aztreonam IV 2 g every 8 hours for Gram-negative coverage
›Add Gram-positive coverage only if indicated by scenario