Treatment of Urinary Tract Infections in the Philippines
For uncomplicated urinary tract infections in the Philippines, first-line treatment options include nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin, with fluoroquinolones reserved for more severe infections due to increasing resistance rates.
Classification and Treatment Approach
Uncomplicated Cystitis (Lower UTI)
First-line options:
- Nitrofurantoin 100 mg twice daily for 5 days 1
- Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (if local resistance rates <20%) 2, 3
- Fosfomycin trometamol 3 g single dose 1
- Amoxicillin-clavulanic acid (as an alternative) 2
Second-line options (use only when first-line options cannot be used):
- Fluoroquinolones (e.g., ciprofloxacin 500-750 mg twice daily for 3 days) 2
Acute Pyelonephritis (Upper UTI)
Outpatient treatment (mild to moderate):
- Ciprofloxacin 500-750 mg twice daily for 7 days (if local resistance <10%) 2
- Levofloxacin 750 mg once daily for 5 days 2, 4
- Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days 2
Inpatient treatment (severe):
- Ceftriaxone 1-2 g once daily 2, 1
- Ciprofloxacin 400 mg twice daily IV 2
- Levofloxacin 750 mg once daily IV 2, 4
- Aminoglycoside (gentamicin or amikacin) with or without ampicillin 2
Complicated UTIs
Complicated UTIs occur in patients with structural or functional abnormalities of the urinary tract, or with underlying conditions that increase infection risk or treatment failure.
Common factors associated with complicated UTIs:
- Urinary obstruction
- Foreign bodies (including catheters)
- Incomplete voiding
- Vesicoureteral reflux
- Recent instrumentation
- Male gender
- Pregnancy
- Diabetes mellitus
- Immunosuppression
- Healthcare-associated infections
- ESBL-producing organisms
- Multidrug-resistant organisms 2
Treatment recommendations:
Initial empiric therapy (based on severity and local resistance patterns):
- Amoxicillin plus an aminoglycoside
- Second-generation cephalosporin plus an aminoglycoside
- Intravenous third-generation cephalosporin 2
Duration: 7-14 days depending on clinical response 2
Special Considerations
Catheter-Associated UTIs
- Remove catheter as soon as possible
- 7-14 day treatment regimen recommended for most patients
- 5-day regimen with levofloxacin may be sufficient for mild cases
- 3-day regimen may be considered for women ≤65 years after catheter removal 2
Recurrent UTIs
- Defined as ≥3 UTIs/year or 2 UTIs in the last 6 months
- Try non-antimicrobial interventions first
- Consider continuous low-dose daily antibiotics for 6-12 months when non-antimicrobial interventions fail 1
Practical Recommendations
Always obtain urine culture before starting antibiotics for complicated UTIs, recurrent UTIs, or treatment failures.
Consider local resistance patterns when selecting empiric therapy. Fluoroquinolone resistance should be <10% for use in pyelonephritis 2.
Avoid treating asymptomatic bacteriuria except in pregnant women 1.
Adjust treatment duration based on clinical response and underlying conditions:
- Uncomplicated cystitis: 3-5 days
- Pyelonephritis: 7-14 days
- Complicated UTIs: 7-14 days (14 days for men when prostatitis cannot be excluded) 2
Monitor for adverse effects of antibiotics, including gastrointestinal disturbances, skin rash, and rare but serious pulmonary/hepatic toxicity 1.
Prevention Strategies
- Increased fluid intake
- Proper hygiene practices
- Urinating before and after sexual activity
- For recurrent UTIs, consider:
- Vaginal estrogen in postmenopausal women
- Low-dose post-coital antibiotics for UTIs related to sexual activity
- Non-antibiotic options like methenamine hippurate or probiotics 1
The increasing prevalence of antibiotic resistance among uropathogens necessitates judicious use of antibiotics and consideration of local resistance patterns when selecting empiric therapy for UTIs in the Philippines.