One-and-Done: Single-Dose Aminoglycosides for Uncomplicated Urinary Tract Infection in the Emergency Department

The objective of this presentation is to encourage consideration of single-dose aminoglycosides in the emergency department (ED) to facilitate safe discharge of otherwise healthy patients with uncomplicated urinary tract infection (UTI) and limited options for effective oral therapy. Aminoglycosides offer a safe option which mitigate barriers common to oral therapies such as local resistance, beta-lactam allergy, insurance coverage, and medication adherence. Recent data and broadened definitions of uncomplicated UTI further strengthen this recommendation. Empiric oral therapies are limited by widespread antimicrobial resistance, as evidenced by a 2022 ED-based study reporting resistance to trimethoprim-sulfamethoxazole and fluoroquinolones in greater than 20% of isolates. In contrast, resistance to aminoglycosides ranged from 0.4% (amikacin) to 7.0% (gentamicin).1 The 2025 IDSA Guidelines for Complicated Urinary Tract Infection redefined uncomplicated urinary tract infection to encompass a broader population, increasing the number of patients in which single-dose therapy could be appropriate.2 The 2022 IDSA Guidelines for Treatment of ESBL-E, CRE, and DTR-P. aeruginosa note that one-time aminoglycosides are “a preferred treatment option” for uncomplicated cystitis caused by P. aeruginosa, and an alternative but safe and effective option for ESBL-E uncomplicated cystitis. These recommendations were based off of a systematic review published in 2019 which found overall microbiological cure in 94.5% of eleven studies, and clinical cure rates of 82.8% and 94.7% in the two studies reporting this outcome. Adverse events occurred in 0.5% of cases, compared to 3.5% in comparator groups.3 Since this systematic review, three notable studies have been published on the subject: a 2024 retrospective review of ESBL-E and P. aeruginosa cystitis, a 2024 prospective review of complicated UTI in the ED, and a 2025 randomized trial based in the ED.4–6 The randomized trial found that empiric therapy with intramuscular gentamicin resulted in 83.3% clinical cure rate compared to 48.1% in the oral antibiotic group for 57 total patients, with 70.0% of patients receiving gentamicin reporting they would prefer this option again.6 In the retrospective study of 66 patients with cystitis from ESBL-E and P. aeruginosa, there was no difference in the primary outcome of rate-of-relapse or readmission rate compared to standard-of-care, with no reports of acute kidney injury or ototoxicity.4 Although the prospective study of complicated UTI management in the ED with single-dose aminoglycosides was limited to 13 patients, 77% reported resolved symptoms after 14 days and none required hospitalization for treatment failure.5 These two studies showing that single-dose therapy remained successful in patients with complicated infection offers further reassurance that IDSA’s new definition of uncomplicated UTI can be safely applied to identify patients who could benefit from this treatment. 1. Faine BA, et al. Acad Emerg Med. 2022;29(9):1096-1105. 2. Trautner BW, et al. Clin Infect Dis Off Publ Infect Dis Soc Am. Published online December 30, 2025:ciaf459. 3. Goodlet KJ, et al. Antimicrob Agents Chemother. 2018;63(1):e02165-18. 4. Bouwman K, et al. Antibiotics. 2024;13(6):552. 5. Jenrette JE, et al. Acad Emerg Med. 2024;31(7):649-655. 6. Peyko V, et al. J Pharm Pract. Published online February 17, 2025:08971900251322368.