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Optimal Care of Complicated UTIs

CE / CME

You’re in the Know: Laying the Foundation for Optimal Care of Complicated UTIs

Pharmacists: 1.00 contact hour (0.1 CEUs)

ABIM MOC: maximum of 1.00 Medical Knowledge MOC point

Physicians: maximum of 1.00 AMA PRA Category 1 Credit™

Nurse Practitioners/Nurses: 1.00 Nursing contact hour

Released: December 31, 2025

Expiration: December 30, 2026

Nicolás Cortés-Penfield
Nicolás Cortés-Penfield, MD, FACP, FIDSA
CME/CE Information

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Defining cUTI: Major Change in IDSA Guidelines

The most recent IDSA guidelines mark a big shift in how we talk about urinary tract infection (UTI). The prior IDSA guidelines held a very specific definition of uncomplicated UTI: cystitis in a woman who is not febrile, is not pregnant, and is premenopausal, without diabetes or any other potentially complicating factors.1

Acute pyelonephritis was defined as its own separate entity: acute kidney infection in women who otherwise meet the narrow definition for uncomplicated UTI.1

Then, all other UTIs were considered complicated.1

The new guidelines flipped the script: They give a very specific definition for cUTI. Now, cUTI is defined as an infection that extends beyond the bladder in people of either gender. That includes pyelonephritis, UTI with fever, bacteremia, or other signs of systemic illness, and catheter-associated UTIs.1

There are a couple of reasons underlying the change in definitions. First, we, the guideline authors, wanted to provide simple definitions of complicated vs uncomplicated UTI to make diagnosis more straightforward. Frankly, we wanted to align the guideline definitions of UTI with the way healthcare professionals (HCPs) actually practice. The goal was to focus on syndromes with higher risk for treatment failure and with more severe consequences if treatment failure occurs.1

We also wanted to intentionally move away from including risk factors like diabetes and gender in the definition of complicated infection. Ultimately, we found that there are insufficient data in the literature to support the claim that these characteristics are important determinants of outcome.1

However, one caveat to the new guidelines is that they do not specifically address prostatitis, epididymitis, orchitis, or patients with indwelling urologic hardware like ureteral stents. The data on how HCPs should manage these conditions is much more limited, and new guidelines focus on conditions that have more robust, randomized clinical trial–based data.1,2  

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Defining cUTI: Are All Men Complicated?

One of the most controversial changes to the guidelines is the removal of male gender as an inherently complicating factor and instead relying on the specific UTI syndrome to determine whether or not infection is complicated and how that affects care.1

To delve into the supporting evidence for this change, we based our decision on 7 trials of cUTI that included men. Overall, treatment outcomes in these trials were similar regardless of duration of therapy.1

Two studies specifically included men who were suspected to have acute bacterial prostatitis, and these studies performed gender-stratified analysis. However, the definition of cure in these studies included not just clinical improvement but microbiologic cure, meaning that urine cultures were free of bacteria. This is arguably less important for patient outcomes and may not be the most relevant definition of cure in real-world settings.1

Nevertheless, these studies did suggest that a shorter duration of antibiotics might slightly reduce the rate of clinical cure in men with acute bacterial prostatitis. Indeed, subgroup analysis in these 2 studies suggested that poorer outcomes were associated with clinical symptoms specifically suggestive of prostatitis, like fever or rectal pain.1

So, the overall recommendation for duration of therapy includes the precaution that men with febrile UTI or men in whom prostatitis is otherwise clinically suspected may need some individualized management.1

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Burden of cUTI

The burden of cUTI is not often discussed, but it is quite substantial. People with cUTIs have more ambulatory visits, longer hospitalizations, and increased healthcare costs. They are at risk of complications from their infections, including sepsis, bacteremia, and significant morbidity and mortality. Certain subpopulations of people who develop cUTIs will go on to have persistent symptoms of pelvic pain, dysuria, and urinary frequency.1,3,4

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