What are the symptoms and treatment options for Urinary Tract Infection (UTI)?

From the Guidelines

Urinary tract infections (UTIs) are typically treated with antibiotics, and for uncomplicated UTIs, first-line treatment includes nitrofurantoin (Macrobid) 100mg twice daily for 5 days, trimethoprim-sulfamethoxazole (Bactrim) DS twice daily for 3 days, or fosfomycin (Monurol) as a single 3g dose, as recommended by the American College of Physicians in 2021 1. The symptoms of UTIs include burning during urination, frequent urination, cloudy or strong-smelling urine, and pelvic pain. If symptoms include fever, back pain, or nausea, seek immediate medical attention as this may indicate a kidney infection. Some key points to consider in the treatment of UTIs include:

• Using first-line therapy dependent on the local antibiogram for the treatment of symptomatic UTIs in women, as recommended by the AUA/CUA/SUFU guideline in 2019 1.
• Treating recurrent UTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than seven days, as recommended by the AUA/CUA/SUFU guideline in 2019 1.
• Considering self-care measures such as ensuring adequate hydration, encouraging urge-initiated voiding and post-coital voiding, and avoiding spermicidal-containing contraceptives, as recommended by the ACR Appropriateness Criteria in 2020 1.
• Using nitrofurantoin when possible as a first-line agent for re-treatment since resistance is low and, if present, decays quickly, as recommended by the Journal of Urology in 2018 1. While waiting for antibiotics to work, patients can drink plenty of water, urinate frequently, and consider over-the-counter pain relievers like phenazopyridine (AZO) for symptom relief. To prevent recurrence, patients can urinate after sexual activity, wipe from front to back, stay hydrated, and consider cranberry products which may help prevent bacterial adhesion to the urinary tract.

From the Research

Symptoms of Urinary Tract Infection (UTI)

• Typical symptoms include frequency, urgency, dysuria/burning sensation, nocturia, suprapubic pain 2
• In women, a self-diagnosis of a UTI with the presence of typical symptoms is accurate enough to diagnose an uncomplicated UTI without further testing 2
• Men with lower UTI symptoms should always receive antibiotics, with urine culture and susceptibility results guiding the antibiotic choice 2

Treatment Options for UTI

• First-line antibiotics for uncomplicated UTI include:
  • Nitrofurantoin for five days 3, 2, 4
  • Fosfomycin in a single dose 3, 5, 2, 6, 4
  • Trimethoprim for three days 5, 2
  • Trimethoprim/sulfamethoxazole for three days 5, 2
  • Pivmecillinam for five days 3, 6
• Second-line options include oral cephalosporins, fluoroquinolones, and β-lactams, such as amoxicillin-clavulanate 3
• Treatment options for UTIs due to ESBLs-producing Enterobacteriales include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 3
• Parenteral treatment options for UTIs due to ESBLs-producing Enterobacteriales include piperacillin-tazobactam, carbapenems, ceftazidime-avibactam, and aminoglycosides including plazomicin 3

Prevention of Recurrent UTIs

• Increased fluids, intake of cranberry products, and methenamine hippurate can prevent recurrent infections 2
• Antibiotic prophylaxis is also effective in preventing recurrence but has a risk of adverse effects and antimicrobial resistance 5, 2