What is the management for urinary tract infection?

Management of Urinary Tract Infections

The optimal management of urinary tract infections requires appropriate antibiotic selection based on infection classification, with first-line treatments including nitrofurantoin (100 mg twice daily for 5 days), trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), or fosfomycin (3 g single dose) for uncomplicated cases. 1

Diagnosis and Classification

Uncomplicated UTI

• Primarily affects otherwise healthy women with normal urinary tract anatomy
• Symptoms include dysuria, frequency, urgency, and suprapubic pain
• Diagnosis can be made based on symptoms without urine culture in healthy non-pregnant women 2, 1
• E. coli is the most common pathogen (80-90% of cases) 3

Complicated UTI

• Occurs in patients with:
  • Anatomical or functional abnormalities
  • Immunocompromised status
  • Pregnancy
  • Male gender
  • Healthcare-associated infections
  • Catheter-associated infections
• Requires urine culture before starting antibiotics 1

Treatment Algorithm

1. Uncomplicated Cystitis in Women

• First-line options (choose one):

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

• Alternative options (if first-line contraindicated):

  • Pivmecillinam 400 mg twice daily for 5 days
  • Cephalexin 500 mg twice daily for 5 days 1
  • Amoxicillin-clavulanate 500/125 mg twice daily for 5 days 1

2. Complicated UTI/Pyelonephritis

• Duration: 7-14 days 1
• Outpatient options:
  • Fluoroquinolones (if local resistance <10%)
  • Third-generation cephalosporins 3
• Inpatient options (for severe cases):
  • Piperacillin-tazobactam
  • Carbapenems
  • Ceftazidime-avibactam (for resistant organisms) 5

3. UTI in Men

• Obtain urine culture before starting antibiotics
• Treat for 7-14 days 6
• Consider urological evaluation for structural abnormalities

4. Catheter-Associated UTI

• Remove catheter if possible 2
• Avoid treating asymptomatic bacteriuria
• Only treat if symptomatic (fever, suprapubic pain, altered mental status) 2
• Base antibiotic selection on culture results

Special Populations

Elderly/Frail Patients

• Consider atypical presentations (confusion, falls, decreased mobility)
• Avoid fluoroquinolones due to risk of adverse effects 2
• Distinguish between asymptomatic bacteriuria (common, don't treat) and true UTI 2
• Consider local resistance patterns when selecting empiric therapy

Pregnant Women

• Screen for and treat asymptomatic bacteriuria
• Safe options include:
  • Nitrofurantoin (avoid near term)
  • Cephalosporins
  • Amoxicillin-clavulanate 1

Prevention Strategies for Recurrent UTI

• Antibiotic prophylaxis options:

  • Trimethoprim-sulfamethoxazole 40/200 mg daily or three times weekly
  • Nitrofurantoin 50-100 mg daily 1

• Non-antibiotic approaches:

  • Increased fluid intake
  • Vaginal estrogen for postmenopausal women
  • Void after intercourse
  • Cranberry products (limited evidence) 1

Common Pitfalls to Avoid

1. Treating asymptomatic bacteriuria - Only treat in pregnancy or before urologic procedures 1

2. Overuse of fluoroquinolones - Reserve for complicated infections due to increasing resistance and adverse effects 5, 1

3. Inadequate treatment duration - Uncomplicated: 3-5 days; Complicated: 7-14 days 1

4. Failure to adjust for renal impairment - Particularly important for levofloxacin and other renally cleared antibiotics 1

5. Not obtaining cultures in complicated cases - Essential for guiding definitive therapy 1

6. Ignoring local resistance patterns - Local antibiograms should guide empiric therapy 1, 5

The management of UTIs continues to evolve with increasing antimicrobial resistance. Recent guidelines emphasize antibiotic stewardship principles and the importance of appropriate diagnosis to avoid unnecessary treatment 2.