What is the recommended treatment for a Strep (Streptococcal) positive Urinary Tract Infection (UTI)?

Treatment of Streptococcal Urinary Tract Infections

For streptococcal urinary tract infections, amoxicillin 500 mg orally every 8 hours for 5-7 days is the recommended first-line treatment. 1

First-Line Treatment Options

Beta-lactams

• Amoxicillin: 500 mg orally every 8 hours for 5-7 days
  • First choice for streptococcal UTIs, particularly Enterococcus faecalis (group D strep)
  • Provides excellent coverage against most streptococcal species
  • Safe during pregnancy if needed 1

Alternative First-Line Options

• Nitrofurantoin: 100 mg orally twice daily for 5 days

  • Effective for uncomplicated lower UTIs
  • Not suitable for upper UTIs/pyelonephritis
  • Contraindicated if CrCl <30 mL/min 1

• Fosfomycin: 3 g single oral dose

  • Convenient single-dose therapy
  • Effective against many streptococcal species including E. faecalis 2
  • Good option for uncomplicated lower UTIs 1

Second-Line Treatment Options

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

  • Consider only if susceptibility is confirmed
  • Resistance may develop with prolonged use against Streptococcus faecalis 3

• Linezolid: 600 mg orally twice daily for 5-7 days

  • Reserved for resistant cases or when first-line options cannot be used 1

Treatment Duration

• Uncomplicated lower UTI: 5-7 days of treatment 1
• Complicated UTI or pyelonephritis: 10-14 days of treatment 1
• Streptococcal infections: Minimum 10-day treatment recommended to prevent sequelae of streptococcal disease 4

Special Considerations

Group B Streptococcus (GBS) UTIs

• High rates of resistance have been reported to:
  • Azithromycin (44.5%)
  • Clindamycin (26%)
  • Erythromycin (36.3%)
  • Tetracycline (81.5%) 5
• No resistance detected to penicillins, making amoxicillin the preferred choice 5

Monitoring and Follow-up

• Clinical improvement should be expected within 48-72 hours of starting treatment
• If symptoms persist, obtain cultures with susceptibility testing
• Routine post-treatment cultures are not indicated if symptoms resolve 1

Important Caveats

• Ensure adequate hydration during treatment 1
• Penicillin should be used with caution in individuals with histories of significant allergies 4
• For penicillin-allergic patients, consider nitrofurantoin or fosfomycin 1
• Investigate underlying urinary tract abnormalities, especially in cases of enterococcal UTIs 1
• Avoid fluoroquinolones for uncomplicated UTIs due to unfavorable risk-benefit ratio 1
• If catheter-associated, remove or exchange the catheter if possible 1

Treatment Algorithm

1. Uncomplicated lower UTI with streptococcal species:

   • First choice: Amoxicillin 500 mg orally every 8 hours for 7-10 days
   • If penicillin allergic: Nitrofurantoin 100 mg twice daily for 5-7 days or Fosfomycin 3 g single dose

2. Complicated UTI or pyelonephritis with streptococcal species:

   • Amoxicillin 500 mg orally every 8 hours for 10-14 days
   • Consider parenteral therapy initially if severe infection

3. Resistant streptococcal UTI:

   • Obtain susceptibility testing
   • Consider Linezolid 600 mg twice daily for 5-7 days