It’s been more than a decade, but the Infectious Diseases Society of America (IDSA) has finally released updated guidelines for complicated urinary tract infections (cUTIs) — and there’s a lot for clinicians to digest.
If you’ve ever found yourself debating whether your 68-year-old patient with well-controlled diabetes qualifies as “complicated,” or wondered whether you really need to give 14 days of antibiotics, this one’s for you.
Emergency physician and educator Dr. Jeremy Driscoll joined Hippo's Dr. Tiffany Proffitt to walk through what’s changed and why it matters. Here are three big takeaways every urgent and primary care clinician should know.
1. The Definition of “Complicated” Got a Major Overhaul
For years, we labeled a UTI as “complicated” based on broad buckets — things like age over 65, male sex, diabetes, or BPH. But those criteria weren’t always evidence-based, and they led to a lot of overtreatment.
The 2025 IDSA guidelines shift focus from risk factors to observable clinical signs:
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Systemic symptoms like fever, chills, flank pain, or CVA tenderness
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Urinary tract devices (e.g., catheters, stents, nephrostomy tubes)
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Obstruction or urinary retention (e.g., stone, severe BPH)
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Bacteremia with a urinary source
So, that otherwise stable man with lower urinary tract symptoms but no systemic findings? He’s not automatically complicated anymore. This change allows us to tailor care more appropriately — and avoid unnecessary escalation.
2. Some Old Antibiotic Favorites Are Out
If nitrofurantoin is your go-to for every UTI, it's time to pause. The updated guidelines clarify that nitrofurantoin should not be used for complicated UTIs due to its poor tissue penetration.
Also on the no-go list: oral fosfomycin.
Instead, for empiric treatment of cUTI, consider:
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Outpatient: fluoroquinolones, TMP-SMX, or amoxicillin-clavulanate (if local resistance patterns allow)
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Inpatient or severe illness: third- or fourth-generation cephalosporins (like ceftriaxone or cefepime), piperacillin-tazobactam, or carbapenems
And don’t forget to use your local antibiogram when selecting empiric therapy, especially for septic or recently hospitalized patients. As Dr. Driscoll reminds us, patients new to your region might be used to different antibiotics, so local resistance patterns matter more than habit.
3. Shorter Durations Are Now the Norm
Gone are the days of 10- to 14-day antibiotic regimens for cUTIs.
The new standard:
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Fluoroquinolones: 5–7 days
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Other agents: 7 days
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Even with Gram-negative bacteremia, 7 days is sufficient if the patient is improving
That’s right, even if the urine culture grows E. coli and the blood culture matches, you can still stop at a week. Shorter courses reduce side effects, lower the risk of C. difficile, and support antimicrobial stewardship, without compromising outcomes.
Practice Pearls for the Busy Clinician
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Get a urine culture before starting antibiotics, whenever feasible.
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Use the four-step framework for empiric antibiotics: assess severity, resistance risk, patient factors, and local antibiogram.
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Reassess if your patient isn’t improving within 48–72 hours — consider imaging or escalation.
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For hospitalized patients, once they’re improving and can take oral meds, switch from IV to PO rather than continuing IV therapy unnecessarily.
Why This Matters
These guideline updates aren’t just academic; they’re designed to make our care safer, more precise, and more effective. For clinicians in primary care, urgent care, and emergency medicine, this is a huge win. We now have clear criteria, refined treatment options, and permission (finally!) to stop overprescribing. To learn more, check out our Urgent Care Reviews and Perspectives podcast episode, "IDSA Guideline Updates: Complicated UTI."
So next time you see that older adult with UTI symptoms, you’ll know exactly what to do — and what not to do.
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