From the Guidelines
The primary treatment for a urinary tract infection (UTI) is a course of antibiotics, with first-line treatments including nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin, as recommended by the AUA/CUA/SUFU guideline 1. For uncomplicated UTIs, these antibiotics can be prescribed for a duration of no longer than seven days, as suggested by the guideline 1. While waiting for antibiotics to work, drinking plenty of water helps flush bacteria from the urinary system, and over-the-counter pain relievers like ibuprofen or acetaminophen can help manage discomfort. Some key points to consider when treating UTIs include:
- Using prior culture data to choose among first-line treatments while culture is pending 1
- Considering antibiotic resistance patterns in the patient and the community (local antibiograms) as well as patient allergies, side effects, and cost 1
- Avoiding treatment of asymptomatic bacteriuria in women with recurrent UTIs, as this can foster antimicrobial resistance and increase the number of recurrent UTI episodes 1
- Using nitrofurantoin as a first-line agent for re-treatment, since resistance is low and, if present, decays quickly 1 For recurrent UTIs, preventive measures include:
- Urinating after sexual activity
- Wiping from front to back
- Staying hydrated
- Avoiding irritating feminine products It is essential to note that UTIs occur when bacteria, usually E. coli from the digestive tract, enter the urinary tract and multiply in the bladder, and if symptoms worsen or include fever, back pain, or nausea, immediate medical attention is necessary, as the infection may have spread to the kidneys 1.
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 Complicated Urinary Tract Infection and Pyelonephritis – Efficacy in Pediatric Patients:
Treatment for UTI:
- 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 1 to 17 years of age, although it is not a drug of first choice in the pediatric population due to an increased incidence of adverse events 3.
From the Research
Treatment Options for UTI
- 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.
Antibiotic Resistance and Treatment
- 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 use of fluoroquinolones is discouraged due to antibiotic resistance and a high burden of adverse events 5.
- Guideline discordance continues in the treatment of uncomplicated urinary tract infections with the overuse of fluoroquinolones and the underuse of first-line antibiotic agents 5.
Clinical Efficacy of Nitrofurantoin
- Nitrofurantoin is at least comparable with other uUTI treatments in terms of efficacy, with clinical cure rates ranging from 51 to 94% and bacteriological cure rates ranging from 61 to 92% 6.
- Patients taking nitrofurantoin reported fewer side effects than other drugs, with the most commonly reported being gastrointestinal and central nervous system symptoms 6.
- Sulfonamides, trimethoprim-sulfamethoxazole, nitrofurantoin, and nalidixic acid are excreted in the urine in high concentration and are active in vitro against usual aerobic gram-negative bacteria 7.