Latest Guidelines for Treating Urinary Tract Infections (UTIs)
The latest European Association of Urology guidelines (2024) recommend a stepwise approach to UTI management, with diagnosis confirmed by urine culture and treatment tailored to the specific UTI type, patient factors, and local resistance patterns. 1
Diagnosis
- Confirm UTI diagnosis with urine culture before starting antibiotics 1
- For recurrent UTIs, diagnosis should be confirmed via urine culture (strong recommendation) 1
- Extensive workup (cystoscopy, abdominal ultrasound) is not recommended for women under 40 with recurrent UTIs without risk factors 1
Treatment of Uncomplicated UTIs
First-line options for uncomplicated cystitis:
- Nitrofurantoin
- Fosfomycin trometamol (single 3g dose)
- Pivmecillinam
- Trimethoprim (only if local resistance rates <20%) 2
Pyelonephritis treatment:
- Fluoroquinolones or cephalosporins are recommended for oral empiric treatment 1
- For hospitalized patients with systemic symptoms, use: 1, 3
- Amoxicillin plus an aminoglycoside
- Second-generation cephalosporin plus an aminoglycoside
- IV third-generation cephalosporin
Important caution:
- Do not use ciprofloxacin and other fluoroquinolones for empirical treatment if:
- Local resistance rate is >10%
- Patient has used fluoroquinolones in the last 6 months
- Patient is from a urology department 1
Complicated UTIs
Definition:
Complicated UTIs include those with:
- Obstruction at any site in the urinary tract
- Foreign body presence
- Incomplete voiding
- Vesicoureteral reflux
- UTI in males
- Pregnancy
- Diabetes mellitus
- Immunosuppression
- Healthcare-associated infections
- ESBL-producing or multidrug-resistant organisms 1
Treatment recommendations:
- Manage any underlying urological abnormality (strong recommendation) 1
- For systemic symptoms, use: 1
- Amoxicillin plus an aminoglycoside
- Second-generation cephalosporin plus an aminoglycoside
- IV third-generation cephalosporin
- Treatment duration: 7-14 days (14 days for men when prostatitis cannot be excluded) 1
- Consider shorter duration (7 days) when patient is hemodynamically stable and afebrile for at least 48 hours 1
Catheter-Associated UTIs
- Major risk factors: female gender, prolonged catheterization, diabetes, longer hospital stays 1
- Signs include: fever, rigors, altered mental status, flank pain, costovertebral angle tenderness, hematuria 1
- Remove catheter as soon as possible to reduce infection risk
Prevention of Recurrent UTIs
Non-antimicrobial measures (try first):
- Increased fluid intake for premenopausal women 1
- Vaginal estrogen replacement for postmenopausal women (strong recommendation) 1
- Immunoactive prophylaxis (strong recommendation) 1
- Methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 1
Other preventive options (weaker evidence):
- Probiotics with proven efficacy for vaginal flora regeneration 1
- Cranberry products (inform patients of contradictory evidence) 1
- D-mannose (inform patients of weak evidence) 1
- Endovesical instillations of hyaluronic acid or hyaluronic acid/chondroitin sulfate combination 1
Antimicrobial prophylaxis:
- Use only when non-antimicrobial interventions have failed (strong recommendation) 1
- Options include continuous or post-coital antimicrobial prophylaxis 1
- Self-administered short-term antimicrobial therapy for patients with good compliance 1
Special Populations
Pregnant women:
- Screen for bacteriuria by urine culture at least once in early pregnancy 4
- Treat asymptomatic bacteriuria in pregnancy (increases risk of pyelonephritis, preterm birth) 4
- First-line antibiotics: nitrofurantoin (avoid near term), fosfomycin, cephalexin 4
- Avoid trimethoprim-sulfamethoxazole in first trimester (teratogenic) and third trimester (neonatal hyperbilirubinemia) 4, 5
- Treatment duration: 5-7 days (single-dose therapy insufficient except for fosfomycin) 4
Postmenopausal women:
Risk factors include:
- History of UTI before menopause
- Urinary incontinence
- Atrophic vaginitis due to estrogen deficiency
- Cystocele
- High postvoid residual urine volume 1
Common Pitfalls to Avoid
- Using fluoroquinolones as first-line therapy despite high resistance rates
- Not obtaining urine culture before starting antibiotics
- Not adjusting therapy when culture results return
- Treating asymptomatic bacteriuria (except in pregnancy)
- Not considering local resistance patterns when selecting empiric therapy
- Failing to manage underlying urological abnormalities in complicated UTIs
- Not differentiating between uncomplicated and potentially obstructive pyelonephritis
By following these evidence-based guidelines, clinicians can provide optimal care for patients with UTIs while promoting antimicrobial stewardship.