What are the treatment options for urinary tract infections (UTIs)?

Treatment Options for Urinary Tract Infections

First-line treatment for uncomplicated UTIs includes nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole for 3 days (if local resistance <20%), or fosfomycin as a single dose, with treatment selection based on local resistance patterns, patient factors, and infection severity. 1

Uncomplicated UTIs

First-line options:

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

Second-line options:

• Fluoroquinolones (e.g., ciprofloxacin): Generally reserved as second-line due to resistance concerns and risk of adverse effects 1

Complicated UTIs and Pyelonephritis

Treatment options:

• Ciprofloxacin: 500-750mg twice daily for 7 days
• Levofloxacin: 750mg daily for 5 days
• Ceftriaxone or Cefotaxime: For severe cases or when parenteral therapy is needed

Duration:

• Complicated UTI/Pyelonephritis: 10-14 days 1
• Emphysematous pyelonephritis: May require longer treatment similar to other severe UTIs 2

Special Populations

Pregnancy:

• Preferred options: Nitrofurantoin, fosfomycin, or cephalexins
• Avoid: Trimethoprim-sulfamethoxazole in first and third trimesters 1

Elderly patients:

• Adjust antibiotic choice based on renal function
• Avoid nitrofurantoin if creatinine clearance <30 mL/min 1

Renal impairment:

• For CrCl <30 mL/min: Fosfomycin 3g single dose is preferred
• Consider aminoglycoside with adjusted dosing if parenteral therapy is needed 1

Asymptomatic bacteriuria:

• Generally not treated except in:
  • Pregnant patients
  • Patients undergoing invasive urologic procedures with expected mucosal bleeding 2
• When treatment is indicated:
  • Pregnancy: 3-5 days depending on antimicrobial used
  • Urologic procedures: Single dose of preoperative prophylaxis 2

Multidrug-Resistant Organisms

For UTIs caused by multidrug-resistant organisms (MDROs), treatment options depend on the specific organism and resistance mechanisms 2:

• Duration of treatment should be based on anatomical location and clinical severity, not modified solely because the organism is resistant 2
• Ensure the antimicrobial:
  1. Has demonstrated activity against the organism
  2. Has proven efficacy for UTI treatment
  3. Is used after appropriate source control 2

Antimicrobial Stewardship

• Deescalation: Strongly recommended when possible based on culture results 2
• Oral therapy: Multiple RCTs show comparable outcomes with IV-only treatment while reducing hospital stay and adverse events 2
• Allergy assessment: Thorough allergy assessment can prevent harms and expand treatment options 2

Prevention of Recurrent UTIs

For patients with recurrent UTIs (≥3 UTIs in 12 months or ≥2 UTIs in 6 months):

• Increased fluid intake: Strongly recommended 1
• Behavioral measures: Voiding after sexual intercourse, avoiding prolonged urine retention 1
• Vaginal estrogen: Strongly recommended for postmenopausal women 1
• Prophylactic antibiotics:
  • Trimethoprim-sulfamethoxazole: 40mg/200mg once daily or three times weekly
  • Nitrofurantoin: 50-100mg daily
  • Cephalexin: 125-250mg daily
  • Fosfomycin: 3g every 10 days 1

Treatment Failure Considerations

If symptoms persist beyond 72 hours of treatment:

• Obtain urine culture
• Change antibiotic based on culture results
• Evaluate for complications or anatomical abnormalities 1

Important Caveats

• Avoid unnecessary treatment of asymptomatic bacteriuria as it represents low-value care and contributes to antimicrobial resistance 2
• Fluoroquinolone use should be restricted due to increased rates of resistance and adverse effects 3
• Accurate diagnosis is crucial - differentiate between asymptomatic bacteriuria and true UTI to prevent unnecessary antibiotic use 4
• For uncomplicated UTIs, pain relief with medications like ibuprofen may be appropriate while awaiting diagnostic results, as the risk of progression to pyelonephritis is low (1-2%) 5