# Antimicrobial Stewardship in Urinary Tract Infections of Dogs and Cats ## Key Takeaways - Bacterial urinary tract infections (UTIs) in dogs and cats are diagnosed by correlating clinical signs (pollakiuria, stranguria, hematuria) with laboratory findings of pyuria and bacteriuria, with quantitative urine culture from cystocentesis being the diagnostic gold standard. - Antimicrobial stewardship dictates that empiric antibiotic therapy should only be initiated when clinical signs and urinalysis strongly support bacterial infection and culture is not immediately feasible; otherwise, culture and susceptibility testing must guide treatment selection. - First-line antimicrobial choices for uncomplicated UTIs include amoxicillin, amoxicillin-clavulanate, trimethoprim-sulfonamide, or nitrofurantoin, with selection critically dependent on regional resistance data and species-specific susceptibility patterns, particularly noting the lower susceptibility of feline *E. coli* to amoxicillin-clavulanate compared to canine isolates. - Critically important antimicrobials such as fluoroquinolones and third-generation cephalosporins should be reserved for culture-confirmed resistant infections or complicated cases, and their empiric use is strongly discouraged to preserve their efficacy. - Treatment durations for uncomplicated cystitis are typically short, ranging from 3 to 7 days, and routine post-treatment cultures in asymptomatic patients are not indicated; reassessment should focus on persistent or recurrent clinical signs. - Regional antibiograms are essential for informed empiric antimicrobial selection, and veterinary practices should actively seek and utilize up-to-date, geographically relevant data to guide prescribing decisions and combat the rise of antimicrobial resistance. --- This article provides a diagnostic reasoning framework for managing bacterial urinary tract infections (UTIs) in dogs and cats, with emphasis on antimicrobial stewardship and judicious drug selection. It is written for practicing veterinarians who seek a structured approach to deciding when antimicrobial therapy is indicated, how to select a first-line agent, and when culture and susceptibility testing should drive the choice. The clinical questions addressed include how to distinguish bacterial cystitis from non-infectious lower urinary tract disease, how to interpret regional resistance data, and how to apply stewardship principles without compromising patient outcomes. Complicated cases, including pyelonephritis, urolithiasis-associated infection, and recurrent or refractory UTIs, are excluded from this article's scope. Antimicrobial stewardship in veterinary practice rests on a simple premise: antimicrobial use is a driver of resistance, and every prescription carries a population-level cost alongside its individual patient benefit. Observational data from Swiss veterinary practices illustrate the gap between actual prescribing and guideline-based care. In a 2019 evaluation of 333 feline lower urinary tract disease cases, 60% received antibiotic therapy, yet only 24% of those prescriptions were judged in complete accordance with consensus guidelines. The most commonly used agents were potentiated aminopenicillins, third-generation cephalosporins, and fluoroquinolones, with median treatment durations of 10 days. A follow-up study after introduction of an online stewardship tool showed the proportion of antimicrobial prescriptions in FLUTD cases fell from 60.1% to 48.8%, with the largest reductions at university hospitals. These findings demonstrate both the prevalence of overprescribing and the measurable effect of structured stewardship interventions. The diagnostic reasoning challenge in UTI management is that clinical signs of lower urinary tract disease are poorly specific for bacterial infection. Pollakiuria, stranguria, hematuria, and periuria occur with equal frequency in sterile inflammatory conditions such as feline interstitial cystitis and in bacterial cystitis. The decision to prescribe an antimicrobial therefore hinges on laboratory confirmation, not on clinical presentation alone. Urinalysis findings of pyuria and bacteriuria support a bacterial etiology, but the diagnostic gold standard remains quantitative urine culture performed on a sample collected by cystocentesis. Free-catch and catheterized samples carry contamination risk that complicates interpretation. When culture is performed, the Clinical and Laboratory Standards Institute breakpoints guide susceptibility interpretation, and regional antibiograms can inform empiric choices when culture results are pending. ## At a Glance | Parameter | Clinical Decision Point | |---|---| | Diagnostic threshold | Quantitative culture from cystocentesis is the reference standard, urinalysis alone is insufficient | | Empiric therapy indication | Only when clinical signs and urinalysis support bacterial infection and culture is not immediately feasible | | First-line drug classes | Amoxicillin, amoxicillin-clavulanate, trimethoprim-sulfonamide, or nitrofurantoin depending on regional resistance data | | Fluoroquinolone and third-generation cephalosporin use | Reserve for culture-confirmed resistant infections or complicated cases | | Treatment duration | Short courses of 3 to 7 days for uncomplicated cystitis, consult current guidelines for specific recommendations | | Culture indications | Recurrent UTI, suspected pyelonephritis, prior antimicrobial exposure within 30 days, or failed response to empiric therapy | | Regional resistance monitoring | Use published regional antibiograms, such as the Midwestern United States data, to guide empiric selection | ## The Bacteriology of Canine and Feline Urinary Tract Infections Escherichia coli dominates as the most frequently isolated uropathogen in both dogs and cats, followed by Staphylococcus pseudintermedius, Proteus mirabilis, Enterococcus species, and Klebsiella species. The spectrum of organizms influences empiric drug selection because susceptibility patterns differ by species and by pathogen. A regional antibiogram from the Midwestern United States, covering 640 canine and 143 feline urinary E. coli isolates collected from 2013 to 2017, found that 92% of canine isolates were susceptible to amoxicillin-clavulanate, while only 53% were susceptible to amoxicillin alone. Feline isolates showed a striking pattern: none were susceptible to amoxicillin-clavulanate or amoxicillin when evaluated against the Clinical and Laboratory Standards Institute breakpoints used in that study. This disparity likely reflects the higher urinary breakpoints applied to canine isolates, illustrating why breakpoint selection and regional data matter more than generic assumptions about drug efficacy. Resistance to other antimicrobial classes was uncommon in that same dataset, with resistance rates of 7% or less among feline isolates and 14% or less among canine isolates for agents including fluoroquinolones, trimethoprim-sulfonamide, and cephalosporins. These figures should not be generalized to other regions, but they establish an important principle: first-generation and second-generation agents often retain activity against common uropathogens, and routine use of broad-spectrum drugs is rarely justified on resistance grounds alone. ## Antimicrobial Classes Used in Urinary Tract Infection Management Beta-lactams remain the most frequently prescribed antimicrobial class for UTIs in small animal practice. Amoxicillin achieves high urine concentrations through renal excretion and is a reasonable first-line choice when susceptibility is confirmed or when regional data support its use. Amoxicillin-clavulanate extends coverage to beta-lactamase-producing organizms, but its broader spectrum carries a higher resistance selection pressure. Third-generation cephalosporins, particularly cefovecin, are prescribed commonly in cats. A 2022 quarterly survey of small animal practices in Minnesota and North Dakota found that cefovecin was the most prescribed antibiotic for cats, accounting for 34.5% of feline antibiotic prescriptions. This pattern is concerning from a stewardship perspective because third-generation cephalosporins are classified as critically important antimicrobials by the World Organization for Animal Health, and their routine use for uncomplicated cystitis is difficult to justify when narrower-spectrum alternatives exist. Fluoroquinolones such as enrofloxacin and pradofloxacin achieve excellent urine concentrations and tissue penetration, but their use should be reserved for culture-confirmed resistant infections. The same principle applies to gentamicin, which retains activity against many multidrug-resistant Gram-negative uropathogens but carries nephrotoxicity risk. Nitrofurantoin offers a stewardship-friendly option for lower urinary tract infection because it concentrates in urine and has minimal systemic distribution, but it is ineffective against Proteus species and has no activity in renal tissue. Trimethoprim-sulfonamide provides good Gram-negative coverage and is a reasonable first-line choice in regions where resistance rates remain low. ## The Role of Regional Antibiograms in Empiric Selection Antibiograms aggregate culture and susceptibility data from a defined population over a specified period, providing a snapshot of resistance patterns that can guide empiric therapy. The Clinical and Laboratory Standards Institute publishes guidelines for constructing and interpreting antibiograms, including recommendations for the number of isolates needed and the frequency of reporting. Veterinary-specific antibiograms are less standardized than human ones, but the same principles apply: data should be recent, geographically relevant, and stratified by species where possible. The Midwestern United States study referenced above is an example of how institutional and private practice data can be combined to produce clinically useful resistance information. Practitioners should seek out regional antibiograms from their own institutions, diagnostic laboratories, or published literature, and should update their empiric choices as resistance patterns shift. ## Stewardship Frameworks and Prescribing Behavior Formal antimicrobial stewardship programs in veterinary medicine remain uncommon, but the available evidence supports their effectiveness. The Swiss studies cited earlier demonstrate that a structured online tool, combined with practice-level education, reduced antimicrobial prescribing for FLUTD by approximately 11 percentage points over two years. The most pronounced change occurred in university hospital settings, where prescribing fell from 67.1% to 49.3% of cases. These results suggest that stewardship interventions work best when they combine accessible decision support with institutional commitment. For the individual practitioner, the practical equivalent is a personal formulary policy: define which antimicrobials are acceptable for first-line empiric use, which require culture confirmation, and which are reserved for documented resistance. This policy should be written down, reviewed annually, and updated when regional resistance data change. ## Diagnostic Sequence for Suspected Urinary Tract Infection The diagnostic pathway begins with signalment, history, and physical examination. Acute onset pollakiuria, stranguria, hematuria, or inappropriate urination supports a lower urinary tract origin. Systemic signs such as fever, lethargy, or caudal abdominal pain raise concern for upper tract involvement or prostatitis in male dogs. The physical examination must include abdominal palpation, rectal palpation in male dogs to assess the prostate, and a neurologic assessment of the perineal region and anal tone. Urinalysis performed on urine collected by cystocentesis provides the first laboratory decision point. Cystocentesis avoids the urethral and distal genital contamination that confounds free-catch samples. Pyuria, bacteriuria, and hematuria support a diagnosis of bacterial cystitis. The absence of pyuria and bacteriuria makes bacterial UTI unlikely, and antimicrobial therapy should be withheld pending culture results or an alternative diagnosis. Urine specific gravity and sediment examination also identify crystalluria, which may point toward urolithiasis instead of infection. Dipstick leukocyte esterase and nitrite testing have limited sensitivity and specificity in dogs and cats and should not replace sediment microscopy. Urine culture with susceptibility testing is indicated when pyuria or bacteriuria is present, when infection is recurrent, when the patient has received antimicrobials within the preceding two weeks, or when comorbidities such as diabetes mellitus, hyperadrenocorticism, or chronic kidney disease exist. Quantitative culture from cystocentesis samples defines significant bacteriuria as greater than 1,000 colony-forming units per milliliter. Lower counts suggest contamination. Culture is also required when selecting a fluoroquinolone or third-generation cephalosporin, because empiric use of these agents is discouraged under stewardship principles. ## Decision Points That Change Management The first decision point is distinguishing bacterial cystitis from non-infectious causes of lower urinary tract signs. Feline lower urinary tract disease frequently presents with identical clinical signs in the absence of infection. Observational data from Swiss practices showed that 60% of cats with feline lower urinary tract disease received antimicrobial therapy, yet only 24% of those prescriptions were judged fully concordant with consensus guidelines [antimicrobial use for selected diseases in cats in Switzerland](https://pubmed.ncbi.nlm.nih.gov/30871537/). This gap between prescribing and guideline recommendations illustrates the central stewardship failure in feline urinary disease. After the introduction of an online stewardship tool, antimicrobial prescribing for feline lower urinary tract disease fell from 60.1% to 48.8%, with the largest reduction at university hospitals [antimicrobial prescriptions in cats before and after an online stewardship tool](https://pubmed.ncbi.nlm.nih.gov/32620170/). The decision to withhold antibiotics in a cat with hematuria and pollakiuria but no bacteriuria is therefore both evidence-based and achievable in practice. The second decision point occurs when culture results return. Susceptibility testing should guide drug selection, but the clinician must also consider drug penetration, renal excretion, and the patient's ability to tolerate the chosen agent. A drug to which the organizm is susceptible in vitro may still fail if it does not achieve adequate urinary concentrations. Beta-lactams, fluoroquinolones, and trimethoprim-sulfonamides reach therapeutic concentrations in urine, whereas clindamycin and macrolides do not and should not be used for bacterial cystitis. The third decision point is the duration of therapy. Uncomplicated cystitis in dogs is commonly treated for 7 to 14 days, but shorter courses are increasingly supported. Cats with bacterial cystitis may require 7 to 14 days of therapy. The clinician should reassess the patient at the end of the treatment course and repeat culture only if clinical signs persist or recur. Routine post-treatment culture in asymptomatic patients is not indicated. ## First-Line Antimicrobial Selection | Clinical Scenario | First-Line Options | Rationale | Stewardship Notes | |---|---|---|---| | Uncomplicated canine cystitis, no recent antimicrobial exposure | Amoxicillin, amoxicillin-clavulanate, trimethoprim-sulfonamide | Narrow spectrum, renal excretion, low cost | Reserve fluoroquinolones and cephalosporins for culture-confirmed resistance | | Uncomplicated feline cystitis, no recent antimicrobial exposure | Amoxicillin-clavulanate, amoxicillin | Narrow spectrum, feline urinary concentrations adequate | Withhold antibiotics if no bacteriuria is confirmed | | Recurrent or complicated UTI | Culture-guided selection | Resistance patterns require individualised therapy | Avoid empiric fluoroquinolones or third-generation cephalosporins | | Culture-confirmed multidrug-resistant Enterobacterales | Fluoroquinolone, nitrofurantoin, or amikacin based on susceptibility | These agents retain activity against many resistant strains | Consult current formulary for dosing and contraindications | Regional antibiogram data inform empiric choices when culture results are pending. A Midwestern United States study found that canine urinary Escherichia coli isolates had 92% susceptibility to amoxicillin-clavulanate but only 53% susceptibility to amoxicillin [amoxicillin and amoxicillin-clavulanate resistance in urinary E. coli antibiograms](https://pubmed.ncbi.nlm.nih.gov/31777977/). Feline isolates in the same study showed no susceptibility to either drug at the breakpoints used, although the authors noted that the feline breakpoint criteria differed substantially from canine criteria. This disparity underscores the need for species-specific and region-specific antibiogram interpretation instead of extrapolation from human data or from other geographic regions. ## Monitoring Parameters and Reassessment Clinical response is the primary monitoring parameter. Pollakiuria, stranguria, and hematuria should improve within 48 to 72 hours of appropriate antimicrobial therapy. Lack of improvement within this window warrants re-evaluation of the diagnosis, urine culture with susceptibility testing, and imaging to exclude urolithiasis, neoplasia, or anatomic abnormalities. Urine culture should be repeated when clinical signs persist after a complete course of therapy, when infection recurs within weeks of treatment completion, or when the initial isolate was multidrug-resistant. Repeat culture is not indicated for asymptomatic patients who have completed therapy. Imaging, including abdominal radiography and ultrasonography, is indicated for recurrent infections, suspected urolithiasis, or when pyelonephritis is considered. Pyelonephritis requires a longer treatment course and may require hospitalization for fluid therapy and parenteral antimicrobials. Adverse drug effects require monitoring specific to the agent selected. Fluoroquinolones carry a risk of arthropathy in juvenile dogs and cats. Trimethoprim-sulfonamides can cause keratoconjunctivitis sicca, hepatopathy, or hypersensitivity reactions. Aminoglycosides require monitoring of renal function and are contraindicated in dehydrated patients or those with pre-existing renal disease. The clinician should document the indication for antimicrobial therapy, the drug selected, the dose, the expected duration, and the planned reassessment date in the medical record. ## Documentation and Stewardship Integration Medical record documentation should state the basis for the UTI diagnosis, the culture results if available, the antimicrobial selected, and the planned duration. When antimicrobials are prescribed without culture confirmation, the record should justify that decision. Practices that track antimicrobial use can identify prescribing patterns that deviate from local guidelines. Quarterly prescribing surveys in Minnesota and North Dakota found that third-generation cephalosporins were the most commonly prescribed systemic antibiotic class, and cefovecin was the most frequently prescribed antibiotic for cats [quarterly survey of antibiotic prescribing in small animal and equine practices](https://pubmed.ncbi.nlm.nih.gov/35643964/). This pattern suggests that convenience formulations may drive drug selection more than susceptibility data or guideline recommendations. Practices should review their own prescribing data against regional antibiograms and published stewardship guidance from professional bodies such as the AVMA [AVMA antimicrobial use and stewardship resources](https://www.avma.org/resources-tools/one-health/antimicrobial-use-and-antimicrobial-resistance). Client communication is part of stewardship. Owners should understand why antimicrobials are not prescribed for every episode of lower urinary tract signs, particularly in cats. They should also understand the importance of completing the prescribed course and returning for reassessment if signs persist. Written instructions that include the expected timeline for improvement and specific criteria for re-evaluation reduce unnecessary return visits and unsanctioned antimicrobial use. ## Recognized Complications and Early Detection The most consequential failure in urinary tract infection management is not antimicrobial resistance itself, but the delayed recognition of its emergence. A patient that fails to improve within 48 to 72 hours of appropriate first-line therapy warrants repeat urine culture and susceptibility testing, not a reflexive change to a broader agent. Clinical deterioration, recurrence of clinical signs after apparent resolution, or growth of a different organizm on repeat culture each suggest distinct failure modes that require different corrective actions. Persistent bacteriuria with the same organizm usually indicates inadequate drug penetration, a foreign body such as a urolith or indwelling catheter, or a sequestered focus such as prostatitis or pyelonephritis. Imaging and urine sediment examination discriminate among these possibilities. Recurrent infection with a different organizm more often reflects reinfection from the environment or perineal contamination, particularly in female dogs, and may signal an underlying structural or functional abnormality that antimicrobial therapy alone will not correct. Subclinical bacteriuria is a recognized entity in dogs and cats, especially in patients with endocrinopathy, chronic kidney disease, or urinary catheterization. Treating it does not improve patient outcomes and selects for resistant organizms. The distinction between true infection and subclinical bacteriuria rests on the presence of clinical signs referable to the urinary tract, not on the magnitude of bacteriuria or pyuria alone. ## Common Errors and Corrective Action Less experienced clinicians frequently treat a positive urine culture without correlating it to clinical signs. A positive culture from a patient without pollakiuria, stranguria, hematuria, or inappropriate urination is subclinical bacteriuria until proven otherwise. The corrective action is to document clinical signs before initiating therapy and to record the expected response date. A second recurring error is the selection of an antimicrobial based on the susceptibility panel alone without considering drug distribution. Nitrofurantoin, for example, achieves therapeutic concentrations in urine but not in renal parenchyma or prostate, so it is inappropriate for pyelonephritis or prostatitis despite an in vitro susceptible result. Fluoroquinolones penetrate tissues well but carry a higher ecological cost and should be reserved for culture-confirmed infections that require them. A third error is the use of potentiated amoxicillin for feline urinary tract infections based on canine expectations. Regional antibiogram data from the Midwestern United States showed no feline urinary Escherichia coli isolates susceptible to amoxicillin-clavulanate at the urinary breakpoint, whereas canine isolates retained 92% susceptibility, a disparity attributed to species-specific breakpoint differences [amoxicillin and amoxicillin-clavulanate resistance in urinary Escherichia coli antibiograms of cats and dogs](https://pubmed.ncbi.nlm.nih.gov/31777977/). Clinicians practising outside that region should consult their own regional cumulative susceptibility data before extrapolating. ## Limitations of the Evidence and Divergent Expert Opinion The evidence base for antimicrobial stewardship in veterinary urinary tract infection is thinner than many practitioners assume. Much of the published guidance derives from observational studies, expert consensus, and extrapolation from human medicine. Prescribing surveys consistently show that a substantial proportion of antimicrobial prescriptions for feline lower urinary tract disease do not comply with consensus guidelines, and that stewardship interventions can shift prescribing behavior, but the clinical outcomes associated with those shifts are less well documented [antimicrobial use for selected diseases in cats in Switzerland](https://pubmed.ncbi.nlm.nih.gov/30871537/), [antimicrobial prescriptions in cats before and after an online stewardship tool](https://pubmed.ncbi.nlm.nih.gov/32620170/). Duration of therapy remains a contested area. Traditional recommendations of 10 to 14 days have been challenged by shorter courses, but comparative data in dogs and cats are limited. Expert opinion differs on whether a 3 to 5 day course is adequate for uncomplicated cystitis in dogs, and some authorities still recommend longer courses for cats. Until higher-quality comparative trials are published, duration decisions should be individualised and documented. The clinical significance of methicillin-resistant staphylococci in urinary tract infection is also debated. These organizms are frequently isolated from urine, but their role as primary uropathogens versus contaminants or commensals is not always clear, and treatment decisions should incorporate clinical context instead of susceptibility results alone [antibiotic stewardship for canine and feline acute urinary tract infection](https://pubmed.ncbi.nlm.nih.gov/34064943/). ## Referral, Consultation, and Reporting Referral to a specialist is warranted for recurrent or refractory urinary tract infection, suspected upper urinary tract involvement, urolithiasis, or any patient requiring repeated courses of fluoroquinolones or third-generation cephalosporins. A veterinary microbiologist or clinical pathologist can assist with interpretation of unusual susceptibility patterns, confirmation of resistance mechanisms, and selection of agents not routinely tested. Laboratory involvement should extend beyond culture and susceptibility. Request minimum inhibitory concentration values instead of susceptible, intermediate, or resistant interpretations alone when managing recurrent infections, because the numerical value informs dose optimization and detects emerging resistance earlier. The Clinical and Laboratory Standards Institute breakpoints used by the laboratory should be stated on the report, as urinary breakpoints differ from systemic breakpoints for several agents. Regulatory reporting obligations vary by jurisdiction. The World Organization for Animal Health terrestrial animal health standards address antimicrobial resistance surveillance and the responsible use of antimicrobial agents in animals, and veterinarians should be aware of the reporting expectations in their region [WOAH terrestrial animal health standards](https://www.woah.org/en/what-we-do/standards/codes-and-manuals/terrestrial-code-online-access/). In the United States, the FDA Center for Veterinary Medicine provides regulatory information on approved drugs, extralabel use, and adverse event reporting [FDA Center for Veterinary Medicine animal drug information](https://www.fda.gov/animal-veterinary). Report suspected adverse drug reactions, including treatment failures associated with suspected counterfeit or compounded products, through the appropriate national system. | Observation | Likely cause | Discriminating check | |---|---|---| | Clinical signs persist beyond 72 hours of therapy | Resistant organizm, poor drug penetration, or incorrect diagnosis | Repeat culture and susceptibility, re-examine urine sediment, imaging for urolith or abscess | | Culture positive, no clinical signs | Subclinical bacteriuria | Confirm absence of pollakiuria, stranguria, hematuria, do not treat | | Recurrence with same organizm | Inadequate duration, sequestered focus, or foreign body | Imaging of bladder and prostate, culture from cystocentesis, consider minimum inhibitory concentration values | | Recurrence with different organizm | Reinfection from environment or anatomic predisposition | Identify and correct predisposing factors, reassess hygiene and underlying disease | | In vitro susceptible but clinical failure | Drug does not reach site of infection | Check drug distribution, nitrofurantoin for pyelonephritis is a classic mismatch | ## Frequently Asked Questions ### How do I manage a suspected urinary tract infection when urine culture is not affordable for the owner? When culture and susceptibility testing are declined, document the financial limitation and proceed with a structured empiric approach. Collect urine by cystocentesis for urinalysis and sediment examination to support the diagnosis. Select a first-line agent guided by regional susceptibility data, since local patterns vary substantially between institutions and regions. The disparity in amoxicillin susceptibility between feline and canine urinary Escherichia coli isolates illustrates why regional antibiograms should inform empiric choices. Schedule a recheck examination and repeat urinalysis 5 to 7 days after completing therapy. If clinical signs persist or recur, explain that culture is then necessary because repeated empiric courses increase resistance pressure without resolving the infection. ### When should I prescribe a fluoroquinolone as first-line therapy for a urinary tract infection? Fluoroquinolones should be reserved for cases where susceptibility testing confirms resistance to first-line agents, or where the patient's condition demands tissue penetration that beta-lactams cannot provide. Observational data from a small animal hospital stewardship program show fluoroquinolones were used in roughly half of canine cases and a quarter of feline cases when therapy was tailored to minimum inhibitory concentration results. Reserve this class for confirmed or strongly suspected multidrug-resistant infections. In cats, third-generation cephalosporins and fluoroquinolones are frequently prescribed, but stewardship interventions can reduce this use without compromising outcomes. Always document the reason for fluoroquinolone selection in the medical record, and reassess once culture results return. ### How should I handle a recurrent urinary tract infection when repeated cultures show the same organizm? Repeat culture and susceptibility testing is mandatory before each treatment course, because susceptibility patterns can shift between episodes. Compare current results with previous isolates to distinguish persistent infection from reinfection. If the same organizm persists despite appropriate therapy, investigate for urolithiasis, anatomic abnormalities, or compromised host defenses. Consider imaging and, where indicated, contrast studies to identify a nidus of infection. Review the previous drug choice, dose, and duration to confirm the regimen was adequate. Consultation with an internal medicine specialist is appropriate when two appropriately treated episodes fail to resolve. Document the recurrence in the record and discuss the rationale for further diagnostics with the owner before prescribing another antimicrobial course. ### What do I tell an owner who expects antibiotics for every episode of lower urinary tract signs? Explain that many cats with lower urinary tract signs do not have a bacterial infection and will not benefit from antibiotics. In a Swiss study of feline lower urinary tract disease, 60% of cases received antibiotic therapy, yet guideline compliance was low, and stewardship interventions subsequently reduced prescribing without apparent harm. Describe the difference between inflammation and infection, and explain that unnecessary antibiotics carry risks including diarrhea, resistance, and cost. Offer a concrete plan: urinalysis and culture first, then targeted therapy if bacteria are confirmed. If the owner insists on immediate treatment, prescribe the narrowest appropriate agent for the shortest evidence-based duration and schedule a recheck. This conversation is an opportunity to build trust through transparency about diagnostic reasoning. ### How do I integrate stewardship principles into a busy practice with limited staff time? Build stewardship into existing workflows instead of adding separate steps. Use a standardized urinalysis and culture submission form that prompts the clinician to record the indication, suspected organizm, and planned duration. Review antimicrobial choices at monthly practice meetings using aggregated culture and susceptibility data. The AVMA provides practice resources on antimicrobial stewardship that can be adapted to individual hospital workflows. Designate one veterinarian or technician as the stewardship lead to answer colleague questions and maintain the regional antibiogram. Track prescribing patterns quarterly, including the proportion of urinary tract infections treated without culture confirmation. These measures require minimal time per case but create accountability and continuous improvement across the practice. ### How does antimicrobial stewardship for urinary tract infections differ between dogs and cats? Feline and canine urinary isolates differ in clinically important ways. In one Midwestern antibiogram study, no feline Escherichia coli isolates were susceptible to amoxicillin or amoxicillin-clavulanate at the tested breakpoints, while canine isolates showed 53% susceptibility to amoxicillin and 92% to amoxicillin-clavulanate. This means empiric amoxicillin is a reasonable choice in dogs but not in cats in that region. Cats also present more frequently with sterile lower urinary tract disease, so the threshold for initiating antibiotics should be higher. Feline patients are more prone to adverse drug reactions, reinforcing the need for narrow-spectrum choices when treatment is indicated. Always consult regional susceptibility data and species-specific breakpoints before selecting empiric therapy. ## Related Clinical & Scientific Guides * [Veterinary Formulary Essentials: Navigating Drug References](/knowledge/veterinary-medicine/clinical-pharmacology/veterinary-formulary-essentials-navigating-drug-references) * [Drug Interactions with Antiepileptic Drugs in Veterinary Patients: Managing Polypharmacy](/knowledge/veterinary-medicine/clinical-pharmacology/drug-interactions-antiepileptic-veterinary) * [Drug Interactions with Corticosteroids in Veterinary Patients: A Comprehensive Review](/knowledge/veterinary-medicine/clinical-pharmacology/drug-interactions-corticosteroids-veterinary-comprehensive) ## References and Further Reading - [Amoxicillin and amoxicillin-clavulanate resistance in urinary Escherichia coli antibiograms of cats and dogs from the Midwestern United States.](https://pubmed.ncbi.nlm.nih.gov/31777977/). 2020. - [Antibiotic Stewardship for Canine and Feline Acute Urinary Tract Infection: An Observational Study in a Small Animal Hospital in Northwest Italy.](https://pubmed.ncbi.nlm.nih.gov/34064943/). 2021. - [Antimicrobial use for selected diseases in cats in Switzerland.](https://pubmed.ncbi.nlm.nih.gov/30871537/). 2019. - [Antimicrobial prescriptions in cats in Switzerland before and after the introduction of an online antimicrobial stewardship tool.](https://pubmed.ncbi.nlm.nih.gov/32620170/). 2020. - [A quarterly Survey of antibiotic prescribing in small animal and equine practices-Minnesota and North Dakota, 2020.](https://pubmed.ncbi.nlm.nih.gov/35643964/). 2022. - [Sulopenem: An Intravenous and Oral Penem for the Treatment of Urinary Tract Infections Due to Multidrug-Resistant Bacteria.](https://pubmed.ncbi.nlm.nih.gov/35294769/). 2022. - [FDA Center for Veterinary Medicine: Animal Drug Information](https://www.fda.gov/animal-veterinary). FDA CVM. - [AVMA Antimicrobial Use and Stewardship](https://www.avma.org/resources-tools/one-health/antimicrobial-use-and-antimicrobial-resistance). American Veterinary Medical Association. - [MSD Veterinary Manual, Professional Edition](https://www.msdvetmanual.com/). MSD Veterinary Manual. ## Related Articles - [Antimicrobial Stewardship in Respiratory Infections of Dogs and Cats](/knowledge/veterinary-medicine/clinical-pharmacology/antimicrobial-stewardship-respiratory-infections-dogs-cats) - [Antimicrobial Stewardship in Feline Urinary Tract Infections: When to Treat and When to Wait](/knowledge/veterinary-medicine/clinical-pharmacology/antimicrobial-stewardship-feline-uti) - [Antimicrobial Stewardship in Canine Postoperative Infections: Prevention and Treatment](/knowledge/veterinary-medicine/clinical-pharmacology/antimicrobial-stewardship-canine-postoperative) - [Antimicrobial Stewardship in Feline Respiratory Infections: When Antibiotics Are Needed](/knowledge/veterinary-medicine/clinical-pharmacology/antimicrobial-stewardship-feline-respiratory) - [Antimicrobial Stewardship in Food Animals: Principles and Practical Application](/knowledge/veterinary-medicine/clinical-pharmacology/antimicrobial-stewardship-food-animals-principles-practical-application) > This article is educational professional reference material for veterinary audiences. It is not a substitute for veterinary diagnosis, individual clinical judgment, current product labeling, or applicable regulatory requirements.