What is the recommended treatment for non-Extended Spectrum Beta-Lactamase (ESBL) urinary tract infections (UTI)?

Treatment of Non-ESBL Urinary Tract Infections

First-line treatment for uncomplicated non-ESBL UTIs should be nitrofurantoin 100 mg twice daily for 5 days, trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 3 days, or fosfomycin trometamol 3 g as a single dose. 1

First-Line Treatment Options

Uncomplicated Cystitis

1. Nitrofurantoin 100 mg twice daily for 5 days

   • Excellent efficacy with minimal impact on normal flora
   • Preserves more broad-spectrum agents for other infections
   • Significantly more effective than placebo for both symptomatic relief and bacteriological cure 2

2. Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 3 days

   • FDA-approved for UTIs caused by susceptible strains of E. coli, Klebsiella, Enterobacter, Morganella morganii, and Proteus species 3
   • Should be used only when local resistance rates are <20%

3. Fosfomycin trometamol 3 g single dose

   • Convenient single-dose administration
   • Good option for patients who may have adherence challenges

Treatment Algorithm Based on UTI Classification

Uncomplicated Lower UTI (Cystitis)

• First-line options:
  • Nitrofurantoin 100 mg twice daily for 5 days
  • TMP-SMX 160/800 mg twice daily for 3 days
  • Fosfomycin trometamol 3 g single dose

Complicated UTI or Pyelonephritis

• Oral treatment options:

  • β-lactams for 7 days 4
  • Fluoroquinolones for 5-7 days (reserve as second-line due to resistance concerns) 4
  • TMP-SMX (if susceptibility confirmed)

• For patients requiring IV therapy:

  • Ceftriaxone is recommended for empiric therapy unless risk factors for multidrug resistance are present 4

Special Considerations

Risk Factors for Resistance

Consider local antibiogram patterns when selecting therapy 1. Risk factors for resistant pathogens include:

• Recent antibiotic use
• Hospitalization
• Recurrent UTIs
• Structural abnormalities
• Catheterization

Pregnant Women

• Screen all pregnant women for bacteriuria
• Treatment options include nitrofurantoin, fosfomycin, and pivmecillinam 1
• Avoid TMP-SMX in late pregnancy

Elderly Patients

• Consider renal function when selecting antibiotics
• Nitrofurantoin should be used with caution in elderly patients due to potential side effects 5

Diagnostic Approach

• Obtain urinalysis, urine culture, and sensitivity prior to initiating treatment for patients with recurrent UTIs 1
• Urine culture is not necessary for uncomplicated first-time UTIs in otherwise healthy women
• Negative urinalysis has excellent negative predictive value for ruling out UTI 4

Prevention Strategies

• Increased fluid intake (strong evidence) 1
• Vaginal estrogen in postmenopausal women (strong recommendation) 1
• Methenamine hippurate 1g twice daily for prophylaxis 1
• Voiding before and after sexual activity
• Avoiding irritating feminine products

Important Caveats

• Fluoroquinolones should be reserved for more invasive infections due to increasing resistance and adverse effects 6, 7
• Avoid treating asymptomatic bacteriuria except in pregnancy 1
• Do not perform surveillance urine cultures in asymptomatic patients 1
• Select antibiotics with minimal impact on normal vaginal and fecal flora to reduce risk of recurrence 1

By following these evidence-based recommendations, clinicians can effectively treat non-ESBL UTIs while practicing good antimicrobial stewardship to minimize the development of resistance.