Guidelines for Treating Common Genitourinary Illnesses
For uncomplicated urinary tract infections (UTIs), first-line treatment should be fosfomycin-trometamol 3g single dose, nitrofurantoin 100mg twice daily for 5 days, or pivmecillinam (where available) due to their efficacy and minimal collateral damage to gut flora. 1
Classification of UTIs
UTIs can be classified as:
- Uncomplicated cystitis: Infection limited to the bladder in otherwise healthy individuals
- Uncomplicated pyelonephritis: Infection of the kidney in patients without structural abnormalities
- Complicated UTI: Infection in patients with underlying genitourinary abnormalities or conditions
First-Line Treatment Options for Uncomplicated Cystitis
- Nitrofurantoin 100mg twice daily for 5 days 1
- Fosfomycin trometamol 3g single dose 1
- Pivmecillinam (not available in some countries including the US) 1
These agents are preferred over traditional options due to:
- Lower resistance rates
- Minimal "collateral damage" (less impact on gut flora)
- Preserved efficacy against common uropathogens 1, 2
Second-Line Treatment Options for Uncomplicated Cystitis
- TMP/SMX 160/800mg twice daily for 3 days (only if local resistance rates <20%) 1, 3
- Fluoroquinolones (e.g., ciprofloxacin 500mg twice daily) should be reserved for more serious infections due to increasing resistance and ecological concerns 1, 4
- Cephalexin or other oral cephalosporins 2
Treatment for Uncomplicated Pyelonephritis
- First-line: Fluoroquinolones (levofloxacin 500mg daily or ciprofloxacin 500mg twice daily) for 5-7 days 1, 4
- Alternative options if fluoroquinolones are contraindicated:
- β-lactams (7-day course)
- Aminoglycosides 1
Treatment Duration
- Uncomplicated cystitis: 3-5 days (depending on antibiotic) 1
- Complicated UTI or pyelonephritis: 5-7 days 1
- Complicated UTI with bacteremia: 7-14 days 1
Special Populations
Pregnant Women
- All pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy 1
- Prophylactic antibiotics should be considered for recurrent UTIs in pregnancy 1
Postmenopausal Women
- Vaginal estrogen therapy is recommended for postmenopausal women without contraindications to help improve urogenital atrophy and reduce UTI risk 1
Management of Complicated UTIs
- Immediate broad-spectrum coverage for sepsis presentation 1
- Empirical coverage against Enterobacteriaceae and Enterococci 1
- For patients with risk factors for resistant organisms:
- Consider hospitalization for IV therapy with agents like ceftazidime-avibactam or meropenem-vaborbactam 1
- Adjust therapy based on culture results
Monitoring and Follow-up
- Clinical follow-up at 3-5 days to evaluate response to treatment 1
- Urine cultures during and after treatment for complicated cases to confirm bacterial eradication 1
Prevention Strategies
- Increased fluid intake for premenopausal women 1
- Vaginal estrogen replacement therapy for postmenopausal women 1
- Consider immunoprophylaxis and probiotics for recurrent UTIs 1
- Products containing cranberry and D-mannose may help reduce recurrent episodes (evidence is limited) 1
- Methenamine hippurate may be used to reduce recurrent episodes in women without urinary tract anomalies 1
Common Pitfalls to Avoid
Overuse of fluoroquinolones: Despite their effectiveness, fluoroquinolones should be reserved for more serious infections due to increasing resistance and risk of adverse effects 1, 4
Treating asymptomatic bacteriuria: Should only be treated in exceptional cases such as pregnancy, prior to urological procedures, or in early post-renal transplant patients 1, 5
Failure to adjust dosing for renal function: Particularly important for levofloxacin, which requires dose adjustment based on creatinine clearance 1, 4
Ignoring local resistance patterns: Treatment should be guided by local antibiotic susceptibility data, especially for empiric therapy 1, 2
Inadequate duration of therapy: Too short a course may lead to treatment failure, while unnecessarily prolonged therapy increases risk of resistance and adverse effects 1