From the Guidelines
For uncomplicated urinary tract infections (UTIs), including cystitis and pyelonephritis, the most effective treatment approach is to prescribe short-course antibiotics, such as nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 days, or fosfomycin as a single dose, as recommended by the American College of Physicians 1. This approach is based on the best practice advice that targets the most common cause of UTIs, Escherichia coli, which accounts for more than 75% of all bacterial cystitis. The treatment options for uncomplicated UTIs include:
- Nitrofurantoin for 5 days
- Trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 days
- Fosfomycin as a single dose For men and women with uncomplicated pyelonephritis, short-course therapy with either fluoroquinolones (5 to 7 days) or TMP-SMZ (14 days) is recommended, based on antibiotic susceptibility 1. It is essential to note that fluoroquinolones should not be prescribed empirically due to their high propensity for adverse effects and should be reserved for patients with a history of resistant organisms. Completing the full course of medication is crucial to prevent antibiotic resistance and recurrence, even if symptoms improve within a few days of starting antibiotics. Additionally, preventive measures such as urinating after sexual activity, wiping from front to back, staying hydrated, and avoiding irritants like scented products can help reduce the risk of recurrent UTIs.
From the FDA Drug Label
To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to empiric selection of therapy Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris It is recommended that initial episodes of uncomplicated urinary tract infections be treated with a single effective antibacterial agent rather than the combination
UTI Treatment:
- Trimethoprim-sulfamethoxazole (PO) can be used to treat urinary tract infections due to susceptible strains of Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris 2.
- Ciprofloxacin (PO) can be used to treat complicated urinary tract infections and pyelonephritis in pediatric patients, but it is not a drug of first choice in the pediatric population due to an increased incidence of adverse events 3.
From the Research
UTI Treatment Options
- The recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females is a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 4.
- Second-line options include oral cephalosporins such as cephalexin or cefixime, fluoroquinolones and β-lactams, such as amoxicillin-clavulanate 4.
- For UTIs due to AmpC- β-lactamase-producing Enterobacteriales, treatment options include nitrofurantoin, fosfomycin, pivmecillinam, fluoroquinolones, cefepime, piperacillin-tazobactam and carbapenems 4.
- For UTIs due to ESBLs-E coli, treatment oral options include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 4.
Special Considerations
- High rates of resistance for trimethoprim-sulfamethoxazole and ciprofloxacin preclude their use as empiric treatment of UTIs in several communities, particularly if patients who were recently exposed to them or in patients who are at risk of infections with extended-spectrum β-lactamases (ESBLs)-producing Enterobacteriales 4.
- The choice of antibiotic substance follows the five primary aspects: individual patient risk and antibiotic pretreatment; bacterial spectrum and antibiotic susceptibility; effectivity of the antimicrobial substance demonstrated in clinical studies; epidemiological effects; and adverse effects 5.
- Asymptomatic bacteriuria (ASB) should only be treated in exceptional cases such as pregnant women or prior to expected mucocutaneous traumatising interventions of the urinary tract 5.
Historical Context
- Traditionally, first-line treatment of acute uncomplicated UTI involved a 3-day regimen of trimethoprim-sulfamethoxazole (TMP-SMX) or TMP alone for patients with sulfa allergies 6.
- Increasing resistance among community-acquired Escherichia coli to TMP-SMX worldwide has led to a reassessment of the most appropriate empiric therapy for these infections 6.
- Sulfonamides, trimethoprim-sulfamethoxazole, nitrofurantoin, and nalidixic acid are excreted in the urine in high concentration and, with the exception of Pseudomonas aeruginosa and Serratia marcescens, are all active in vitro against usual aerobic gram-negative bacteria 7.