What is the recommended treatment for an uncomplicated urinary tract infection (UTI)?

Treatment of Uncomplicated Urinary Tract Infection

For uncomplicated urinary tract infections, first-line treatment options include fosfomycin trometamol 3g single dose, nitrofurantoin 100mg twice daily for 5 days, or trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days. 1, 2

First-Line Treatment Options

For Women:

• Fosfomycin trometamol: 3g single dose (1 day)

  • Advantages: Convenient single-dose regimen, high efficacy against common uropathogens
  • Recommended only for uncomplicated cystitis 1

• Nitrofurantoin:

  • Macrocrystals: 50-100mg four times daily for 5 days
  • Monohydrate/macrocrystals: 100mg twice daily for 5 days
  • Macrocrystals prolonged release: 100mg twice daily for 5 days 1
  • Excellent efficacy with 95.6% susceptibility against E. coli with only 2.3% resistance rate 3
  • Superior clinical resolution (70%) compared to fosfomycin (58%) in a recent randomized trial 4

• Pivmecillinam: 400mg three times daily for 3-5 days 1

Alternative Options:

• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days

  • Contraindicated in last trimester of pregnancy 1, 5
  • Higher resistance rates (29%) compared to nitrofurantoin (2.3%) 3

• Cephalosporins (e.g., cefadroxil): 500mg twice daily for 3 days

  • Only if local E. coli resistance is <20% 1

• Trimethoprim: 200mg twice daily for 5 days

  • Not recommended in first trimester of pregnancy 1

Treatment in Men

• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1
  • Note that men require longer treatment duration than women

Diagnostic Considerations

• Diagnosis can be made with high probability based on focused history of lower urinary tract symptoms (dysuria, frequency, urgency) and absence of vaginal discharge 1
• Urine culture is not necessary for uncomplicated cases but recommended for:
  • Suspected pyelonephritis
  • Symptoms that don't resolve within 4 weeks after treatment
  • Women with atypical symptoms
  • Pregnant women 1

Treatment Approach for Recurrent UTIs

• Document positive urine cultures associated with prior symptomatic episodes 1
• Patient-initiated treatment (self-start) may be offered to select patients with recurrent UTIs 1
• For women whose symptoms don't resolve by end of treatment or recur within 2 weeks, obtain urine culture and sensitivity testing 1
• Retreatment should use a different agent for 7 days if the original treatment fails 1

Important Considerations

• Avoid unnecessary antibiotic use to prevent antimicrobial resistance
• Symptomatic therapy (e.g., ibuprofen) may be considered for women with mild to moderate symptoms as an alternative to antimicrobial treatment 1
• Post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1
• Consider local resistance patterns when selecting antimicrobial therapy
• Nitrofurantoin is contraindicated in patients with renal impairment (CrCl <60 mL/min) 2

The European Association of Urology, American Urological Association, and World Health Organization all recommend nitrofurantoin as a first-line option due to its high efficacy and favorable resistance profile 2.