From the Guidelines
For uncomplicated urinary tract infections, clinicians should prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim–sulfamethoxazole for 3 days, or fosfomycin as a single dose. This recommendation is based on the best practice advice from the American College of Physicians, as published in the Annals of Internal Medicine in 2021 1. The treatment approach varies depending on the type of UTI, with uncomplicated cystitis and pyelonephritis requiring different durations and types of antibiotics.
Uncomplicated Cystitis
For women with uncomplicated bacterial cystitis, the recommended treatment options include:
- Nitrofurantoin for 5 days
- Trimethoprim–sulfamethoxazole for 3 days
- Fosfomycin as a single dose These options are effective against Escherichia coli, which accounts for more than 75% of all bacterial cystitis cases.
Uncomplicated Pyelonephritis
For men and women with uncomplicated pyelonephritis, the recommended treatment options include:
- Fluoroquinolones for 5 to 7 days
- Trimethoprim–sulfamethoxazole for 14 days The choice of antibiotic should be based on antibiotic susceptibility.
It is essential to note that fluoroquinolones are highly efficacious but have a high propensity for adverse effects, and therefore should not be prescribed empirically. Instead, they should be reserved for patients with a history of resistant organisms. Patients should complete the full antibiotic course, even if symptoms improve quickly, and seek medical attention immediately if symptoms worsen or include fever above 101°F, back pain, nausea, or vomiting.
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 CLINICAL STUDIES Complicated Urinary Tract Infection and Pyelonephritis – Efficacy in Pediatric Patients:
UTI Treatment Options:
- Trimethoprim-sulfamethoxazole: 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: can be used to treat complicated urinary tract infections and pyelonephritis in pediatric patients, with clinical success and bacteriologic eradication rates similar to those of the comparator group 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.
- For men with lower UTI symptoms, first-line antibiotics include trimethoprim, trimethoprim/sulfamethoxazole, and nitrofurantoin for seven days 5.
- Second-line options include oral cephalosporins such as cephalexin or cefixime, fluoroquinolones and β-lactams, such as amoxicillin-clavulanate 4.
- Treatment options for UTIs due to ESBLs-E coli include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 4.
- Parenteral treatment options for UTIs due to ESBLs-producing Enterobacteriales include piperacillin-tazobactam, carbapenems, ceftazidime-avibactam, and aminoglycosides including plazomicin 4.
Considerations for Treatment
- The choice of antibiotic should be based on the pharmacokinetic characteristics of the molecule to optimize clinical benefit and minimize the risk of antibacterial resistance 6.
- Increasing antibiotic resistance rates and epidemiological side effects of antibiotics have warranted an update of the guidelines on uncomplicated UTI 7.
- 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 7.
- The ever-increasing incidence of antimicrobial resistance of the common uropathogens in uUTI has been and is a continuing focus of intensive study 8.