What is the recommended treatment for a bladder infection?

Treatment of Bladder Infections

For uncomplicated bladder infections (cystitis), first-line treatment options include nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin, with amoxicillin-clavulanic acid as an alternative. 1

First-Line Treatment Options

Uncomplicated Cystitis in Otherwise Healthy Adults

• Nitrofurantoin: 100 mg twice daily for 5 days 2, 3
• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days (only if local resistance <20%) 4, 3
• Fosfomycin: 3 g single dose 2, 3
• Pivmecillinam: Where available 1, 3

Alternative/Second-Line Options

• Amoxicillin-clavulanic acid: 500/125 mg three times daily for 7 days 1, 2
• Oral cephalosporins (e.g., cephalexin, cefixime) 3
• Fluoroquinolones (e.g., ciprofloxacin): Should be reserved for more serious infections due to safety concerns and increasing resistance 1, 5

Treatment Selection Considerations

Antimicrobial Resistance

• Local resistance patterns should be considered when selecting empiric therapy 1, 2
• Fluoroquinolones should not be used as first-line agents due to:
  • Increasing resistance rates in many regions 1
  • FDA warnings about serious side effects affecting tendons, muscles, joints, nerves, and central nervous system 1
• Trimethoprim-sulfamethoxazole should only be used if local resistance is <20% 2, 3
• Plain amoxicillin is not recommended due to high resistance rates (median 75% of E. coli urinary isolates) 1, 2

Patient-Specific Factors

• Renal function: Avoid nitrofurantoin if creatinine clearance <30 mL/min 2
• Pregnancy status: Treatment options differ (not covered in evidence)
• History of recent antibiotic exposure: Avoid same class of antibiotics 3
• Risk for ESBL-producing organisms: Consider alternative agents 3

Special Situations

Complicated UTI or Pyelonephritis

• First-line: Ceftriaxone or ciprofloxacin 1
• For severe cases: Consider parenteral therapy with amikacin, ceftriaxone, or cefotaxime 1
• Longer treatment duration (10-14 days) is typically required 2

Catheter-Associated UTI

• Only treat symptomatic infections 1
• Replace or remove indwelling catheter before starting antimicrobial therapy 1
• Follow recommendations for complicated UTI 1
• Do not use prophylactic antimicrobials to prevent catheter-associated UTI 1

Treatment Duration

• Uncomplicated cystitis: 3-5 days depending on the agent 2, 4, 3
• Complicated UTI/pyelonephritis: 10-14 days 2

Common Pitfalls to Avoid

1. Overtreatment duration: Studies show high rates of non-adherence to recommended shorter durations (91.33%), leading to unnecessary antibiotic exposure, increased costs, and potential adverse effects 6

2. Treating asymptomatic bacteriuria: Do not treat asymptomatic bacteriuria except before urologic procedures 1

3. Using fluoroquinolones as first-line: Reserve these for more serious infections due to safety concerns and to prevent further resistance 1, 5

4. Not obtaining cultures when indicated: Cultures should be obtained before starting therapy in complicated cases, catheterized patients, or when resistance is suspected 1, 2

5. Not considering local resistance patterns: Treatment success depends on choosing antibiotics with low local resistance rates 1, 2, 3

Follow-up

• Clinical response should be assessed within 48-72 hours of starting treatment 2
• Repeat cultures are only necessary if symptoms persist beyond 48-72 hours of appropriate therapy 2