Treatment of Urinary Tract Infections (UTIs)
For uncomplicated and complicated UTIs, first-line treatments include fosfomycin trometamol, nitrofurantoin, and pivmecillinam for women with uncomplicated cystitis, while fluoroquinolones and extended-spectrum cephalosporins are recommended for pyelonephritis. 1
Diagnosis of UTIs
- Uncomplicated cystitis can be diagnosed based on typical symptoms (dysuria, frequency, urgency) without vaginal discharge in women 1, 2
- Urine culture is recommended in specific situations:
- Suspected acute pyelonephritis
- Symptoms that persist or recur within 4 weeks after treatment
- Women with atypical symptoms
- Pregnant women 1
- For men with UTI symptoms, urine culture with susceptibility testing should always be performed 2
Treatment of Uncomplicated Cystitis in Women
First-line treatments:
- Fosfomycin trometamol: 3g single dose 1, 3
- Nitrofurantoin:
- Pivmecillinam: 400mg three times daily for 3-5 days 1
Alternative treatments:
- Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days (if local resistance rates <20%) 1, 4
- Trimethoprim: 200mg twice daily for 5 days (not in first trimester of pregnancy) 1
- Cephalosporins (e.g., cefadroxil): 500mg twice daily for 3 days (if local E. coli resistance <20%) 1
Important considerations:
- Fluoroquinolones are effective but should be reserved for more serious infections due to collateral damage and resistance concerns 1
- β-lactams (except pivmecillinam) have inferior efficacy and more adverse effects compared to other UTI antimicrobials 1
- Amoxicillin or ampicillin should not be used for empirical treatment due to poor efficacy and high resistance rates 1
- For women with mild to moderate symptoms, symptomatic therapy (e.g., ibuprofen) may be considered as an alternative to antibiotics 1, 2
Treatment of UTIs in Men
- Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1
- Fluoroquinolones can be prescribed according to local susceptibility testing 1
- Treatment duration should be 7 days 1, 2
- Consider the possibility of urethritis and prostatitis in men with UTI symptoms 2
Treatment of Pyelonephritis
Outpatient treatment:
- Oral ciprofloxacin: 500mg twice daily for 7 days (if local resistance <10%) 1
- Once-daily oral fluoroquinolones: ciprofloxacin 1000mg extended release for 7 days or levofloxacin 750mg for 5 days 1
- If fluoroquinolone resistance >10%, add initial IV dose of long-acting parenteral antimicrobial (e.g., ceftriaxone 1g) 1
Inpatient treatment:
- IV antimicrobial regimens:
- Fluoroquinolone
- Aminoglycoside (with or without ampicillin)
- Extended-spectrum cephalosporin or penicillin (with or without aminoglycoside)
- Carbapenem 1
- Choice should be based on local resistance patterns and tailored based on susceptibility results 1
Oral β-lactams:
- Less effective than other agents for pyelonephritis 1
- If used, add initial IV dose of long-acting parenteral antimicrobial 1
- Treatment duration: 10-14 days 1
Management of Recurrent UTIs
- Defined as ≥3 UTIs per year or ≥2 UTIs in 6 months 1
- Diagnosis requires urine culture confirmation 1
- Prevention strategies:
- Increased fluid intake for premenopausal women 1
- Vaginal estrogen replacement for postmenopausal women 1
- Immunoactive prophylaxis 1
- Methenamine hippurate 1
- Probiotics containing strains proven effective for vaginal flora regeneration 1
- Cranberry products (limited evidence) 1
- D-mannose (limited evidence) 1
- Continuous or postcoital antimicrobial prophylaxis when non-antimicrobial interventions fail 1
- Self-administered short-term antimicrobial therapy for patients with good compliance 1
Treatment Failure
- For women whose symptoms don't resolve by end of treatment or recur within 2 weeks:
- Perform urine culture and antimicrobial susceptibility testing
- Assume the infecting organism is resistant to the original agent
- Retreat with a 7-day regimen using another agent 1
- Patients with trimethoprim-resistant organisms have significantly worse clinical outcomes, including longer time to symptom resolution and higher reconsultation rates 5
Special Considerations
- Local resistance patterns should guide empiric therapy choices 1
- Antimicrobial stewardship principles should be followed to minimize resistance 6
- Post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1
- In elderly but non-frail adults without relevant comorbidities, treatment recommendations are similar to those for younger adults 2