What are the recommended treatments for uncomplicated and complicated urinary tract infections (UTIs)?

Treatment Guidelines for Urinary Tract Infections (UTIs)

First-line therapy for uncomplicated UTIs should include nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, with treatment duration generally no longer than seven days. 1, 2

Diagnosis of UTIs

• Diagnosis based on symptoms including:
  • Dysuria (painful urination)
  • Urinary frequency
  • Urgency to urinate
  • Nocturia
  • Suprapubic discomfort 2
• Urinalysis showing moderate to large leukocytes and positive nitrites
• Significant bacteriuria defined as ≥50,000 CFUs/mL of a single uropathogen or pure growth of 250,000 CFUs/mL with bacteriuria/pyuria 2
• Bacterial counts >10,000 CFU/mL of a uropathogen are considered confirmatory 2

Treatment Algorithm for UTIs

Uncomplicated UTIs in Women

1. First-line therapy options (choose one based on local antibiogram):

   • Nitrofurantoin: 5-day course
   • Trimethoprim-sulfamethoxazole (TMP-SMX): 3-day course (if local resistance <20%)
   • Fosfomycin: single 3g dose 1, 2, 3

2. Second-line options (use only when first-line agents cannot be used):

   • Oral cephalosporins (cephalexin, cefixime)
   • Fluoroquinolones (reserve for cases with resistant organisms)
   • Amoxicillin-clavulanate 2, 4

Complicated UTIs

1. Obtain urine culture before starting antibiotics 1, 2
2. Initial empiric therapy:
   • Parenteral antibiotics may be needed for severe cases
   • Cefepime: 0.5-1g IV every 12 hours for mild-moderate cases; 2g IV every 12 hours for severe cases (7-10 days) 5
   • Adjust therapy based on culture results

Pyelonephritis

1. Outpatient treatment (mild-moderate cases):

   • Third-generation cephalosporins preferred 6
   • Fluoroquinolones (when susceptibility is known) 2
   • Duration: 7-14 days

2. Inpatient treatment (severe cases):

   • Parenteral antibiotics (e.g., cefepime 1-2g IV every 8-12 hours) 5
   • Duration: 10-14 days

Special Populations

Pregnant Women

• Screen for and treat asymptomatic bacteriuria
• Safe options include:
  • Standard short-course treatment
  • Single-dose fosfomycin trometamol 2
• Hospitalization and IV antibiotics for pyelonephritis 6

Diabetic Patients

• Do not screen for or treat asymptomatic bacteriuria 2
• Control blood glucose to reduce UTI risk 2
• Consider vaginal estrogen replacement therapy for postmenopausal women 2

Elderly Patients

• Obtain urine culture with susceptibility testing
• First-line antibiotics and treatment durations similar to younger adults 3
• Avoid aminoglycosides due to high risk of nephrotoxicity and ototoxicity 2

Recurrent UTIs Prevention

1. Non-antibiotic measures:

   • Increased fluid intake (strong recommendation) 2
   • Methenamine hippurate (first-line for women without urinary tract abnormalities) 2
   • Immunoactive prophylaxis 2
   • Vaginal estrogen for postmenopausal women 6
   • Voiding after sexual intercourse 2

2. Antibiotic prophylaxis (when non-antibiotic measures fail):

   • Most effective but increases risk of resistance 6
   • Consider patient-initiated treatment (self-start) for select patients with recurrent UTIs 1

Important Caveats and Pitfalls

1. Avoid treating asymptomatic bacteriuria except in pregnant women and patients undergoing invasive urinary procedures 1, 2

2. Avoid fluoroquinolones as first-line therapy due to:

   • Increasing resistance rates
   • Risk of collateral damage
   • Should be reserved for pyelonephritis or complicated UTIs with resistant organisms 2, 4

3. Avoid routine surveillance urine testing in asymptomatic patients with history of recurrent UTIs 1

4. Obtain cultures before starting antibiotics in:

   • Recurrent UTIs
   • Treatment failures
   • Patients with history of resistant organisms
   • Atypical presentations 3

5. Reevaluate diagnosis and therapy if symptoms persist after 3 days of treatment 2

By following these evidence-based guidelines, clinicians can effectively manage both uncomplicated and complicated UTIs while practicing good antimicrobial stewardship.