What is the recommended treatment for urinary tract infections (UTIs)?

Treatment of Urinary Tract Infections (UTIs)

For uncomplicated cystitis, nitrofurantoin is the recommended first-line treatment at a dose of 100 mg twice daily for 5 days due to its efficacy, safety profile, and low resistance rates. 1

First-Line Treatment Options for Uncomplicated UTIs

Preferred Agents:

• Nitrofurantoin: 100 mg twice daily for 5 days 2, 1

  • High urinary concentrations
  • Low resistance rates
  • Preserves broader-spectrum agents for other infections
  • Avoid if CrCl <30 mL/min 1

• Trimethoprim-sulfamethoxazole (TMP-SMX): 160/800 mg twice daily for 3 days 2, 1, 3

  • Use only if local E. coli resistance rates <20% 1, 4
  • FDA-approved for urinary tract infections 3

• Fosfomycin: 3g single dose 2, 1

  • Slightly less effective than multi-day regimens
  • Convenient single-dose administration

• Pivmecillinam: 400 mg three times daily for 3-5 days (where available) 1

Second-Line Treatment Options

• Beta-lactams (e.g., amoxicillin-clavulanate, cephalexin):

  • Less effective than first-line agents 1
  • Associated with higher recurrence rates 1
  • Consider only when first-line agents cannot be used
  • Duration: 3-7 days 2, 1

• Fluoroquinolones (e.g., ciprofloxacin, levofloxacin):

  • Should be reserved as last resort due to 1, 5:
    • Risk of serious adverse effects
    • High resistance rates
    • Need to preserve effectiveness
  • Duration: 3 days for cystitis 2

Treatment Based on UTI Type

Uncomplicated Cystitis

• Use first-line agents as described above
• Obtain urine culture before starting antibiotics if recurrent or complicated UTI suspected 2, 1

Pyelonephritis

• Outpatient treatment:

  • TMP-SMX or first-generation cephalosporin (if local resistance rates permit) 2
  • Beta-lactams: 7 days 2
  • Fluoroquinolones: 5-7 days 2

• Inpatient treatment:

  • Ceftriaxone is recommended for patients requiring IV therapy (unless risk factors for multidrug resistance) 2
  • Duration: 7 days for gram-negative bacteremia from urinary source 2

Recurrent UTIs

• Confirm diagnosis: >2 culture-positive UTIs in 6 months or >3 in one year 2
• Implement prevention strategies before considering prophylactic antibiotics:
  • Postmenopausal women: Vaginal estrogen with or without lactobacillus probiotics 2, 1
  • Premenopausal with post-coital infections: Low-dose antibiotic within 2 hours of sexual activity 2
  • Non-antibiotic alternatives: Methenamine hippurate and/or lactobacillus probiotics 2, 1

Special Considerations

Pregnancy

• Avoid fluoroquinolones (risk of fetal cartilage damage) 1
• Avoid tetracyclines (contraindicated) 1
• Avoid TMP-SMX in first trimester (neural tube defects) and third trimester (kernicterus) 1
• For pyelonephritis in pregnancy: hospitalization and IV antibiotics indicated 4

Antimicrobial Stewardship

• Do not treat asymptomatic bacteriuria (promotes resistance without clinical benefit) 1
• Do not perform surveillance urine cultures in asymptomatic patients 1
• Avoid prolonged treatment courses (>7 days) as they increase adverse effects without improving outcomes 1
• Consider local resistance patterns when selecting empiric therapy 1, 6

Common Pitfalls to Avoid

1. Overdiagnosis: UTIs are often diagnosed inappropriately when patients have asymptomatic bacteriuria 4
2. Overuse of broad-spectrum antibiotics: Increases risk of C. difficile infection and antimicrobial resistance 1
3. Inadequate treatment duration: Too short may lead to treatment failure; too long increases resistance and side effects
4. Ignoring local resistance patterns: Local antibiograms should guide empiric therapy 2, 1
5. Treating without symptoms: Avoid treating positive urine cultures without clinical symptoms 1

By following these evidence-based recommendations, clinicians can effectively treat UTIs while practicing good antimicrobial stewardship to minimize the development of resistance.