From the Guidelines
The first-line treatment for uncomplicated urinary tract infections (UTIs) in women is typically a short course of oral antibiotics, with nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin being the most commonly recommended options, as stated in the 2024 European Association of Urology guidelines 1.
Treatment Options
- Nitrofurantoin (Macrobid) 100 mg twice daily for 5 days
- Trimethoprim-sulfamethoxazole (Bactrim) 160/800 mg twice daily for 3 days
- Fosfomycin (Monurol) 3 grams as a single dose These antibiotics target the most common UTI pathogen, Escherichia coli, which causes about 80-90% of uncomplicated UTIs.
Rationale
The choice of antibiotic should be based on the local antibiogram and the patient's medical history, as recommended by the American Urological Association and the European Association of Urology guidelines 1.
Additional Recommendations
- Patients should drink plenty of water to help flush bacteria from the urinary tract.
- Phenazopyridine (Pyridium) 100-200 mg three times daily can be used for 1-2 days to relieve painful urination while waiting for antibiotics to take effect.
- If symptoms worsen or don't improve within 48-72 hours, patients should seek further medical evaluation as this may indicate antibiotic resistance or a complicated infection requiring different treatment, as suggested by the American College of Physicians 1.
From the FDA Drug Label
Fosfomycin tromethamine granules for oral solution is indicated only for the treatment of uncomplicated urinary tract infections (acute cystitis) in women due to susceptible strains of Escherichia coli and Enterococcus faecalis. The recommended dosage for women 18 years of age and older for uncomplicated urinary tract infection (acute cystitis) is one sachet of fosfomycin tromethamine granules for oral solution.
The first-line treatment for uncomplicated urinary tract infections (UTIs) in women is fosfomycin tromethamine granules for oral solution, with a recommended dosage of one sachet for women 18 years of age and older. This treatment is specifically indicated for acute cystitis caused by susceptible strains of Escherichia coli and Enterococcus faecalis 2. The dosage can be taken with or without food, but the granules must be mixed with water before ingesting 2.
From the Research
First-Line Treatment for Uncomplicated UTIs in Women
The first-line treatment for uncomplicated urinary tract infections (UTIs) in women typically involves a short course of antibiotics. According to 3, 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
- A 5-day course of pivmecillinam
Comparison of Treatment Options
A study published in 4 compared the clinical and microbiologic efficacy of nitrofurantoin and fosfomycin in women with uncomplicated cystitis. The results showed that:
- 5-day nitrofurantoin resulted in a significantly greater likelihood of clinical and microbiologic resolution at 28 days after therapy completion compared to single-dose fosfomycin
- Clinical resolution through day 28 was achieved in 70% of patients receiving nitrofurantoin vs 58% receiving fosfomycin
Traditional Pharmacologic Therapies
Traditional pharmacologic therapies for UTIs, as discussed in 5 and 6, have included:
- Trimethoprim-sulfamethoxazole (TMP-SMX) or TMP alone for patients with sulfa allergies
- Fluoroquinolones, nitrofurantoin, and fosfomycin as alternative first-line agents
Contemporary Management
The contemporary management of uncomplicated UTIs, as outlined in 7, takes into account the increasing incidence of antimicrobial resistance among common uropathogens. Key considerations include:
- The use of fluoroquinolones as first-line agents when local uropathogen resistance rates to cotrimoxazole exceed 10-25%
- The recommendation against single-dose therapy due to suboptimal cure rates and high relapse rates
- The use of nitrofurantoin and fosfomycin as second-line therapies, with nitrofurantoin given for 7 days and fosfomycin given as a single dose