What is the recommended treatment for a patient with a urinary tract infection (UTI)?

From the Guidelines

The recommended treatment for a urinary tract infection (UTI) is typically antibiotics, with first-line treatment being either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days, or fosfomycin as a single dose for uncomplicated cystitis, as recommended by the American College of Physicians 1.

Treatment Options

• For uncomplicated cystitis, the following antibiotics are recommended:
  • Nitrofurantoin 100 mg twice daily for 5 days
  • Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 3 days
  • Fosfomycin as a single dose
• For uncomplicated pyelonephritis, the following antibiotics are recommended:
  • Fluoroquinolones for 5-7 days
  • TMP-SMX for 14 days

Additional Recommendations

• Patients should drink plenty of water to help flush bacteria from the urinary system
• Over-the-counter pain relievers such as ibuprofen or acetaminophen can help manage discomfort
• Phenazopyridine (Pyridium) can specifically relieve urinary pain but should be used only for 2-3 days
• Patients should complete the full course of antibiotics even if symptoms improve, avoid caffeine, alcohol, and spicy foods which can irritate the bladder, and follow up with a healthcare provider if symptoms don't improve within 48 hours of starting treatment, as suggested by the AUA/CUA/SUFU guideline 1

Considerations

• The choice of antibiotic should be based on the local antibiogram and the patient's medical history, as recommended by the European Association of Urology guidelines 1
• Fluoroquinolones should be used with caution due to their potential for adverse effects and resistance, and should be reserved for patients with a history of resistant organisms or when other options are not suitable.

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

The recommended treatment for a patient with a urinary tract infection (UTI) is a single effective antibacterial agent, such as trimethoprim-sulfamethoxazole or ciprofloxacin, for the treatment of urinary tract infections due to susceptible strains of certain organisms, including:

• Escherichia coli
• Klebsiella species
• Enterobacter species
• Morganella morganii
• Proteus mirabilis
• Proteus vulgaris 2 3

From the Research

Treatment Options for Urinary Tract Infections (UTIs)

• 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.

Duration of Therapy for Complicated UTIs

• A study found that 7 days of antibiotics appears effective for hospitalized patients with complicated UTIs when antibiotics with comparable intravenous and oral bioavailability are administered; 10 days may be needed for all other patients 5.
• The study also found that there was no difference in the odds of recurrent infection for patients receiving 10 days and those receiving 14 days of therapy 5.

Recurrent UTIs and Prophylactic Antibiotics

• Risk factors for recurrent UTI include diabetes mellitus, chronic renal disease, and use of immunosuppressive drugs, renal transplant, any form of urinary tract catheterization, immobilization, and neurogenic bladder 6.
• Prophylactic antibiotics, such as nitrofurantoin, Bactrim, or amoxicillin-clavulanic acid, can be effective in reducing recurrent UTI episodes, emergency room visits, and hospital admissions due to UTIs 6.
• Patients who received continuous prophylactic antibiotics experienced significantly less episodes of urinary tract infections, emergency room visits, and hospital admissions due to urinary tract infections 6.

Diagnosis and Management of UTIs

• Acute uncomplicated cystitis in women can be diagnosed without an office visit or urine culture 7.
• Trimethoprim-sulfamethoxazole, nitrofurantoin monohydrate/macrocrystals, and fosfomycin trometamol are all appropriate first-line therapies for uncomplicated cystitis 7.
• Immediate antimicrobial therapy is recommended rather than delayed treatment or symptom management with ibuprofen alone 7.