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Pharmacists are essential in ensuring safe and effective medication use, playing a critical role in antimicrobial stewardship. Antimicrobial stewardship involves the appropriate use of antibiotics to effectively treat infections while minimizing harm from incorrect or unnecessary antibiotic use. When antibiotics are misused, patients face risks such as allergic reaction or disruption of their natural microbiome without any clinical benefit. When used appropriately, antibiotics can cure bacterial infections, speed-up recovery, limit the spread of disease, and even save lives. Inappropriate antibiotic use fuels antibiotic resistance. Antibiotic resistance is a means by which bacteria evolve mechanisms to survive treatments that would normally kill them or prevent their growth. As a result, infections become harder to treat, leading to longer illness and greater risk of death. The spread of antibiotic-resistant organisms poses a serious threat to public health. This is where pharmacists can step in and help reduce the emergence of antibiotic resistance.

Pharmacist-led antimicrobial stewardship interventions improve antibiotic use, enhance patient outcomes, and reduce healthcare costs. By promoting and implementing current clinical guidelines, pharmacists can make evidence-based antimicrobial decisions and educate providers and patients about responsible antibiotic use.

Infectious Diseases Society of America (ISDA) is an association of physicians, scientists, pharmacists, and other healthcare providers who are experts in infectious disease. They promote patient care, education, and research in the area of infectious disease. IDSA recently published 2025 practice guidelines for the treatment and management of complicated urinary tract infections. Pharmacists should actively apply these guidelines to ensure patients receive the most effective and appropriate care for these infections.

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Background

In 2010, IDSA published 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. These guidelines focused on uncomplicated urinary tract infections and pyelonephritis in healthy women who were premenopausal, not pregnant, and with no structural or functional urologic abnormalities. The 2010 guidelines did not address urinary tract infections (UTI) in men or complicated urinary tract infections.

On July 17, 2025, IDSA released guidelines for the treatment of complicated UTI: Clinical Practice Guideline by Infectious Diseases Society of America (IDSA): 2025 Guideline on Management and Treatment of Complicated Urinary Tract Infections. These guidelines address the management and treatment of complicated urinary tract infections in both men and women for the first time. By broadening recommendations, the guidelines better reflect real-world practice and fill gaps in UTI management.

New Classifications

The 2025 guidelines lay out new classifications of uncomplicated and complicated UTI for both men and women.

Empiric Antibiotic Selection

Complicated UTIs often involve resistant pathogens or have systemic involvement, making appropriate empiric antibiotic selection crucial. Pharmacists play a key role in the selection of empiric therapies by ensuring coverage of the most likely pathogens and verifying the selection is suitable for the patient. Pharmacist interventions can improve time to optimal therapy by initiating empiric treatment in a timely manner.

The 2025 IDSA guidelines utilize a stepwise approach to selecting empiric antibiotic therapies for complicated UTI. These steps determine which antibiotics are appropriate based on presentation and patient-specific factors.

• Step 1: Determine the severity of illness – Is the patient septic or not?
• Step 2: Determine patient risk factors for resistant pathogens – Consider the patient’s prior antibiotic exposure and any recent resistant urine cultures.
• Step 3: Determine patient-specific factors for adverse effects – Consider drug-drug interactions, contraindications, and allergies.
• Step 4: If septic, utilize local antibiogram if relevant to the patient – Is the patient similar to the patient population utilized in the creation of the antibiogram?

Using this approach, pharmacists and clinicians can select appropriate initial therapies. IDSA guidelines prioritize antibiotic selection based on whether or not the patient is septic. Sepsis is the body’s extreme response to an infection. Patients with sepsis may present with fever and elevated heart rate, respiratory rate, and white blood cell count.

Some patients can be managed in the outpatient setting using oral antibiotics.

Definitive Antibiotic Therapy

Pharmacists can contribute to antimicrobial stewardship by optimizing the de-escalation of antibiotic therapies from broad-spectrum antibiotics to more targeted therapies. This reduces the patient’s exposure to broad-spectrum antibiotics, leading to fewer adverse effects and helps curb antibiotic resistance. Pharmacists should verify that definitive therapy is appropriate for the patient and is effective against the infectious organism.

In complicated urinary tract infection, IDSA guidelines recommend de-escalating antibiotic therapies once identification and susceptibilities are available from urine cultures.

IV to Oral Transition

In patients with complicated UTI, it may be favorable to transition IV antibiotics to oral. IV antibiotics require additional time and resources that oral antibiotics don’t. IV antibiotics require intravenous access which may result in IV-related complications and patient discomfort. Administration of IV antibiotics requires longer hospital stays, additional nursing resources, and greater healthcare costs. Oral antibiotics are more convenient for healthcare providers and for most patients.

2025 IDSA guidelines for complicated UTI recommend switching from IV to oral antibiotics once the following criteria are met:

• The patient is showing clinical improvement
• The patient is able to take medications by mouth
• An effective oral antibiotic is available

Pharmacists can help identify patients who are eligible to switch from IV to oral, ensure proper drug selection, and verify equivalent dosing. They can also educate patients, which has been shown to improve adherence.

Duration of Therapy

Treating infections for the proper length of time is another way pharmacists can be good antimicrobial stewards. Antibiotics should be used for the shortest effective duration. Research has shown that infections are often treated longer than necessary which can promote the development of drug-resistant organisms. Longer durations of therapy are more inconvenient to patients and increase the risk of adverse effects. Pharmacists should monitor for appropriate durations of therapy and adjust therapies that are too long. In addition to reducing antibiotic use, reduced duration leads to shorter hospital length of stay and reduced costs.

2025 IDSA guidelines recommend that in patients with complicated UTI, duration of therapy is based on whether or not the patient is clinically improving.

If patients are not clinically improving, it is important to do the following:

• Ensure the antibiotic covers the organism
• Assess for additional sources of infection
• Look for differential diagnoses
• Plan for a longer duration of therapy

There are exceptions that may require longer durations of therapy. For instance, men with acute bacterial prostatitis may benefit from a treatment duration of 10-14 days.

Conclusion

The 2025 complicated UTI guidelines create a framework for treating infections while optimizing antibiotic use. The four-step approach to antibiotic selection, emphasis on de-escalation, and shorter duration of therapy enforce the importance of patient care while promoting antimicrobial stewardship.

Pharmacists can take an active role in healthcare by advocating for the use of current guidelines and ensuring appropriate antibiotic use. With their knowledge of medications and antimicrobial stewardship, pharmacists are essential to optimizing patient care and antibiotic use.

Terese H., APPE Student

Resources

1. Infectious Diseases Society of America. Complicated Urinary Tract Infections (cUTI): Clinical Guidelines for Treatment and Management. Published 17 July 2025, Infectious Diseases Society of America, https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections/. Accessed 8/25/26.
2. Infectious Diseases Society of America. Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update. Infectious Diseases Society of America, 1 Mar. 2011, https://www.idsociety.org/practice-guideline/uncomplicated-cystitis-and-pyelonephritis-uti/. Accessed 8/25/26.
3. Centers for Disease Control and Prevention. Antibiotic Use and Stewardship in the United States, 2024 Update: Progress and Opportunities. National Center for Emerging and Zoonotic Infectious Diseases, 20 Nov. 2024, https://www.cdc.gov/antibiotic-use/hcp/data-research/stewardship-report.html Accessed 8/25/26.
4. World Health Organization. Antimicrobial Stewardship Interventions: A Practical Guide. World Health Organization, 2021.
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6. Infectious Diseases Society of America. “About Us.” Infectious Diseases Society of America, www.idsociety.org/about-us/#:~:text=We’re%20committed%20to%3A,infectious%20diseases%20content%20and%20expertise. Accessed 27 Aug. 2025.
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