Treatment of Urinary Tract Infections (UTIs)
For uncomplicated UTIs in adult women, first-line empiric treatment should be nitrofurantoin (50-100mg four times daily for 5-7 days), fosfomycin (3g single dose), or trimethoprim-sulfamethoxazole (if local resistance is <20%) for 3 days. 1, 2
Diagnosis and Initial Assessment
- Confirm diagnosis with urine culture before starting antibiotics, especially for recurrent UTIs
- Distinguish between uncomplicated cystitis and complicated UTI (structural/functional abnormalities, immunosuppression, pregnancy)
- Assess for recurrent UTIs: defined as ≥3 UTIs in 1 year or ≥2 in 6 months 3
Treatment Algorithm for UTIs
Uncomplicated Cystitis in Women
First-line options:
- Nitrofurantoin 50-100mg four times daily for 5-7 days
- Fosfomycin 3g single dose
- Trimethoprim-sulfamethoxazole for 3 days (only if local resistance <20%)
Second-line options:
- Oral cephalosporins (cephalexin)
- Amoxicillin-clavulanate
- Fluoroquinolones (reserve due to resistance concerns)
Complicated UTIs
- Treatment duration: 7-14 days
- Obtain urine culture before starting antibiotics
- Consider broader-spectrum antibiotics based on local resistance patterns
- Reassess therapy once culture results are available
Pyelonephritis
- Treatment duration: 10-14 days
- Third-generation cephalosporins are preferred 3
- Consider hospitalization for severe cases, especially in pregnancy
Special Populations
Postmenopausal Women with Recurrent UTIs
Premenopausal Women with Recurrent UTIs
- For UTIs related to sexual activity: low-dose post-coital antibiotics within 2 hours of intercourse for 6-12 months 4, 1
- For UTIs unrelated to sexual activity: low-dose daily antibiotic prophylaxis for 6-12 months 4, 1
Pregnant Women
- Screen for asymptomatic bacteriuria in early pregnancy
- Treat asymptomatic bacteriuria to prevent pyelonephritis and reduce risk of preterm birth
- Avoid fluoroquinolones and tetracyclines 1
Prevention of Recurrent UTIs
Non-antibiotic Options
- Methenamine hippurate (1g twice daily) 4, 1
- Lactobacillus-containing probiotics 4, 1
- Cranberry products with minimum 36 mg/day proanthocyanidin A (PAC) 1
- Self-care measures: adequate hydration (2-3L daily), urge-initiated voiding, post-coital voiding, avoiding spermicidal contraceptives 1
Antibiotic Prophylaxis
- Nitrofurantoin 50-100 mg daily at bedtime is the most studied regimen 1
- Post-coital prophylaxis with cephalexin 250mg or nitrofurantoin 50mg as a single dose within 2 hours after intercourse 1
Management of Persistent UTIs
- For persistent symptoms after treatment, obtain repeat urine culture before prescribing additional antibiotics 4, 1
- Assess for complicating factors (structural/functional abnormalities)
- Consider non-infectious causes (interstitial cystitis, urethral syndrome, pelvic floor dysfunction)
Important Caveats
- Avoid treating asymptomatic bacteriuria except in pregnancy 1
- Avoid classifying patients with recurrent UTIs as "complicated" as this often leads to use of broad-spectrum antibiotics 4
- Consider local antibiotic resistance patterns when selecting empiric therapy
- Reserve fluoroquinolones for situations where other antibiotics cannot be used due to increasing resistance 2
- Escherichia coli remains the most common uropathogen 2, 3