What are the treatment options for urinary tract infection (UTI) management?

Management of Urinary Tract Infections (UTIs)

For the treatment of urinary tract infections, nitrofurantoin is recommended as a first-line treatment for uncomplicated UTIs due to its low resistance rates, with a recommended dosage of 100 mg twice daily for 5 days. 1

Diagnosis and Classification

UTIs are classified based on:

• Location (upper vs. lower urinary tract)
• Severity (uncomplicated vs. complicated)
• Patient factors (age, pregnancy status, comorbidities)

Complicated UTIs

Complicated UTIs occur when patients have host-related factors or anatomic/functional abnormalities that make infection more difficult to eradicate, including:

• Obstruction in the urinary tract
• Foreign bodies
• Incomplete voiding
• Vesicoureteral reflux
• Recent instrumentation
• Pregnancy
• Diabetes mellitus
• Immunosuppression
• Healthcare-associated infections
• Presence of multidrug-resistant organisms 2

Treatment Recommendations

Uncomplicated Cystitis in Adults

First-line options:

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

Second-line options:

• Fluoroquinolones for 3 days (use only when first-line agents cannot be used) 2
• Cephalosporins (e.g., cephalexin, cefixime) 3
• Amoxicillin-clavulanate 3

Pyelonephritis in Adults

Oral treatment options:

• TMP/SMX 160/800 mg twice daily for 14 days (if susceptible) 2
• Ciprofloxacin 500 mg twice daily for 7 days (if local resistance <10%) 2
• Levofloxacin 750 mg daily for 5 days 2
• Cefpodoxime 200 mg twice daily for 10 days 2
• Ceftibuten 400 mg daily for 10 days 2

For patients requiring IV therapy:

• Ceftriaxone is recommended for empirical therapy (unless risk factors for multidrug resistance) 2

Pediatric UTIs

For febrile infants with UTIs:

• Parenteral options: ceftriaxone, cefotaxime, ceftazidime, gentamicin, tobramycin, piperacillin 2
• Oral options: amoxicillin-clavulanate, TMP/SMX, cephalosporins 2
• Total course: 7-14 days 2

Note: Nitrofurantoin should not be used in febrile infants with UTIs as it may not achieve adequate serum concentrations to treat pyelonephritis 2

Prevention of Recurrent UTIs

Recurrent UTIs are defined as >2 culture-positive UTIs in 6 months or >3 in one year 1. Prevention strategies include:

• Increased water intake: Additional 1.5L of water daily 2
• Cranberry products: Containing proanthocyanidin levels of 36 mg 2
• Vaginal estrogen: Recommended for postmenopausal women 2, 1
• Methenamine hippurate: 1g twice daily 2, 1
• Antimicrobial prophylaxis options:
  • Continuous: TMP/SMX 40mg/200mg daily or 3 times weekly; Nitrofurantoin 50-100mg daily 2
  • Postcoital: TMP/SMX 40mg/200mg or 80mg/400mg; Nitrofurantoin 50-100mg 2, 1

Special Populations

Pregnant Women

• All pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy 1
• Any bacteriuria during pregnancy requires treatment 1
• First-line options: nitrofurantoin, fosfomycin, pivmecillinam, TMP/SMX (avoid in first trimester) 1

Catheter-Associated UTIs

• Catheterization duration is the most important risk factor 2
• Urinalysis has excellent negative predictive value but low specificity 2
• Urine cultures are not reliable tests for patients with chronic urinary catheters 2

Antibiotic Resistance Considerations

For UTIs caused by resistant organisms:

• ESBL-producing E. coli: nitrofurantoin, fosfomycin, pivmecillinam 3, 4
• AmpC β-lactamase producers: nitrofurantoin, fosfomycin, fluoroquinolones, cefepime, piperacillin-tazobactam, carbapenems 3, 4
• Carbapenem-resistant Enterobacteriales: ceftazidime-avibactam, meropenem/vaborbactam, colistin, fosfomycin, aminoglycosides 3, 4

Important Caveats

• Avoid treating asymptomatic bacteriuria (except in pregnancy) 1
• Avoid performing surveillance urine cultures in asymptomatic patients 1
• Limit fluoroquinolone use due to adverse effects and increasing resistance 1, 4
• Post-treatment follow-up is not necessary for asymptomatic patients after treatment completion 1

The management of UTIs requires consideration of local resistance patterns, patient factors, and antimicrobial stewardship principles to ensure optimal outcomes while minimizing the development of resistance.