What is the recommended treatment for urinary tract infections (UTIs)?

Treatment of Urinary Tract Infections (UTIs)

For uncomplicated cystitis, nitrofurantoin 100 mg twice daily for 5 days is the recommended first-line treatment due to its high efficacy and low resistance rates. 1, 2

First-Line Treatment Options for Uncomplicated UTIs

Uncomplicated Cystitis in Adults

• Nitrofurantoin: 100 mg twice daily for 5 days 1, 2
• Fosfomycin trometamol: 3 g single dose 2
• Pivmecillinam: 400 mg three times daily for 3-5 days 2
• Trimethoprim-sulfamethoxazole (TMP-SMX): 160/800 mg twice daily for 3 days (only if local resistance rates <20%) 1, 2, 3

Duration of Treatment for Uncomplicated Cystitis

Antimicrobial	Duration
Nitrofurantoin	5 days
Fosfomycin	Single dose
TMP-SMX	3 days
Pivmecillinam	3 days
Fluoroquinolones	3 days (not recommended as first-line due to collateral damage)

Treatment for Complicated UTIs

Pyelonephritis

• Oral therapy (for mild to moderate cases):

  • β-lactams: 7 days 1
  • Fluoroquinolones: 5-7 days 1

• Initial IV therapy (for severe cases, followed by oral therapy):

  • Ceftriaxone (preferred for empiric therapy without risk factors for multidrug resistance) 1
  • Total duration: 7 days for uncomplicated cases 1, 2

Catheter-Associated UTI

• Remove or change catheter if possible
• Treatment duration based on severity and response to therapy
• Consider local resistance patterns when selecting antimicrobials

Special Populations

Pregnant Women

• Avoid TMP-SMX in first and third trimesters 2
• Fosfomycin is a recommended option 2
• Screen all pregnant women for asymptomatic bacteriuria in first trimester 2

Men with UTI

• Longer treatment duration (7 days) recommended 2
• Consider evaluation for underlying structural abnormalities

Recurrent UTIs

• Non-antimicrobial interventions should be tried first:
  • Increased fluid intake
  • Proper hygiene practices
  • Urinating before and after sexual activity
• If non-antimicrobial interventions fail, consider prophylaxis:
  • Methenamine hippurate: 1 gram twice daily
  • Low-dose post-coital antibiotic (single dose within 2 hours of intercourse)
  • Low-dose daily antibiotic for 6-12 months 2

Important Considerations

Antimicrobial Resistance

• Obtain urine culture before starting antibiotics for complicated UTIs, suspected pyelonephritis, persistent/recurrent symptoms, or in pregnant women 2
• Avoid fluoroquinolones as first-line therapy due to increasing resistance and adverse effects 2
• Check local resistance patterns before prescribing TMP-SMX (should only be used if local resistance <20%) 2, 4

Common Pitfalls to Avoid

1. Treating asymptomatic bacteriuria unnecessarily (except in pregnant women) 2
2. Using broad-spectrum antibiotics for uncomplicated UTIs
3. Prolonged treatment courses that increase risk of resistance without improving outcomes
4. Failure to adjust therapy based on culture results in complicated cases
5. Using agents with antipseudomonal activity in patients without risk factors for nosocomial pathogens 1

Algorithm for UTI Treatment Decision-Making

1. Assess severity and complication factors:

   • Uncomplicated: healthy non-pregnant women with normal urinary tract
   • Complicated: men, pregnant women, abnormal urinary tract, immunocompromised, healthcare-associated

2. For uncomplicated cystitis:

   • Start with nitrofurantoin, fosfomycin, or pivmecillinam
   • Use TMP-SMX only if local resistance <20%

3. For pyelonephritis:

   • Mild-moderate: oral β-lactams or fluoroquinolones
   • Severe: initial IV therapy with ceftriaxone, then step down to oral therapy

4. For complicated UTIs:

   • Obtain cultures before starting antibiotics
   • Consider broader coverage based on risk factors
   • Adjust therapy based on culture results

By following these evidence-based recommendations, clinicians can effectively treat UTIs while minimizing antimicrobial resistance and optimizing patient outcomes.