Module 4: When & How to Treat a UTI

This module is organized into four content sections. Each section includes a slide deck presentation. Additional links and resources are also provided. A complete reference list is included at the end of the module.

Section 1 provides a discussion of the clinical decision about when to treat a suspected urinary tract infection and the five moments of antibiotic decision-making.
Section 2 presents basic principles related to initiating treatment, along with guidance about empiric treatment of uncomplicated and complicated urinary tract infection.
Section 3 reviews opportunities to modify existing antibiotic therapy and reviews antibiotic timeout.
Section 4 provides an overview of the collaborative role of the pharmacist in antibiotic stewardship, along with sample documents related to a Collaborative Practice Agreement.

Section 1: When to Treat -+

UTI Stoplight
When to Test Nursing Tool
Active Monitoring Tracking Form

When to Treat PowerPoint (PPTX) (PDF)

Section 2: How to Treat -+

Provider Prescribing Brochure

How to Treat PowerPoint (PPTX) (PDF)

Section 3: Antibiotic Time Out -+

Antibiotic Time Out PowerPoint (PPTX) (PDF)

Section 4: Collaborative Role of the Pharmacist -+

Sample CPA Agreement
Sample CPA Policy
Sample CPA Cover Letter

Collaborative Role of the Pharmacist PowerPoint (PPTX) (PDF)

Additional Resources -+

Johns Hopkins ABX Guide: Urinary Tract Infection, Complicated (UTI) This links to recommendations for the treatment of complicated UTI (requires a paid subscription).

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Glomerular Filtration Rate (GFR) Calculator A freely available online GFR calculator that includes adjustment for race and gender. This calculator otherwise only requires resident serum creatinine (mg/dL) and age. A recent weight is not required to provide an estimated GFR.

Cockcroft-Gault Creatinine Clearance Equation (MDCalc) This freely available online calculator that estimates an individual’s creatinine clearance based on their gender, age, weight and serum creatinine (mg/mL).

Reference List-+

Crnich CJ, Drinka, PJ. Improving the Management of Urinary Tract Infections in Nursing Homes: It’s Time to Stop the Tail From Wagging the Dog. Ann Long Term Care 2014;22(9):32-6.
Nace DA, Drinka PJ, Crnich CJ. Clinical Uncertainties in the Approach to Long Term Care Residents with Possible Urinary Tract Infection. J Am Med Dir Assoc 2014;15(2):133-9. PMID: 2446120.
Brown KA, Khanafer N, Daneman N, Fisman DN. Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother 2013 May;57(5):2326-32. doi: 10.1128/AAC.02176-12. PMID: 23478961.
Tandan M, Cormican M, Vellinga A. Adverse events of ﬂuoroquinolones vs. other antimicrobials prescribed in primary care: A systematic review and meta-analysis of randomized controlled trials. Int J Antimicrob Agents 2018;52:529-40. doi: 10.1016/j.ijantimicag.2018.04.014.
Daneman N, Lu H, Redelmeier DA. Fluoroquinolones and collagen associated severe adverse events: a longitudinal cohort study. BMJ Open 2015 Nov 18;5(11):e010077. doi: 10.1136/bmjopen-2015-010077. PMID: 26582407.
FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together.
Drekonja DM, Rector TS, Cutting A, Johnson JR. Urinary tract infection in male veterans: treatment patterns and outcomes. JAMA Intern Med 2013 Jan 14;173(1):62-8. doi: 10.1001/2013.jamainternmed.829. PMID: 23212273.
Nace DA, Perera SK, Hanlon JT, Saracco S, Anderson G, Schweon SJ, Klein-Fedyshin M, Wessel CB, Mulligan M, Drinka PJ, Crnich CJ. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents. J Am Med Dir Assoc 2018 Sep;19(9):765-769.e3. doi: 10.1016/j.jamda.2018.05.030. PMID: 30037743.
Hanlon JT, Perera S, Drinka PJ, Crnich CJ, Schweon SJ, Klein-Fedyshin M, Wessel CB, Saracco S, Anderson G, Mulligan M, Nace DA. The IOU Consensus Recommendations for Empirical Therapy of Cystitis in Nursing Home Residents. J Am Geriatr Soc 2019 Mar;67(3):539-545. doi: 10.1111/jgs.15726. PMID: 30584657.
University of Nebraska-Urinary Tract Infection and Asymptomatic Bacteriuria Guideline.
Gupta K, Hooton TM, Miller L; Uncomplicated UTI IDSA Guideline Committee. Managing uncomplicated urinary tract infection--making sense out of resistance data. Clin Infect Dis 2011 Nov;53(10):1041-2. doi: 10.1093/cid/cir637. PMID: 21940416.
Hossin T, Bahranian M, Taylor L, Nace D, Crnich CJ. Estimating the impact of post-prescribing review on the quality of antibiotic prescribing in skilled nursing facilities. Open Forum Infect Dis 2017; 4(Suppl 1): S160.
Lee TC, Frenette C, Jayaraman D, Green L, Pilote L. Antibiotic self-stewardship: trainee-led structured antibiotic time-outs to improve antimicrobial use. Ann Intern Med 2014 Nov 18;161(10 Suppl):S53-8. doi: 10.7326/M13-3016. PMID: 25402404.
Jones M, Butler J, Graber CJ, Glassman P, Samore MH, Pollack LA, Weir C, Goetz MB. Think twice: A cognitive perspective of an antibiotic timeout intervention to improve antibiotic use. J Biomed Inform 2017 Jul;71S:S22-S31. doi:10.1016/j.jbi.2016.06.005. PMID: 27327529.
CDC Core Elements of Antibiotic Stewardship in Nursing Homes
2013 Wisconsin Act 294