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

Treatment Guidelines for Urinary Tract Infections (UTIs)

First-line treatment for uncomplicated cystitis in women should include fosfomycin trometamol (3g single dose), nitrofurantoin (100mg twice daily for 5 days), or pivmecillinam (400mg three times daily for 3-5 days), based on the most recent European Association of Urology guidelines. 1

Diagnosis of UTIs

• Diagnosis of uncomplicated cystitis can be made with high probability based on focused history of lower urinary tract symptoms (dysuria, frequency, urgency) and absence of vaginal discharge 1
• Urine culture is recommended in specific situations:
  • Suspected acute pyelonephritis
  • Symptoms that don't resolve or recur within 4 weeks after treatment
  • Women with atypical symptoms
  • Pregnant women 1
• For recurrent UTIs, diagnosis should be confirmed via urine culture (strong recommendation) 1

Treatment of Uncomplicated Cystitis

First-line treatments for women:

• Fosfomycin trometamol: 3g single dose (1 day) 1
• Nitrofurantoin macrocrystals: 50-100mg four times daily for 5 days 1
• Nitrofurantoin monohydrate/macrocrystals: 100mg twice daily for 5 days 1
• Pivmecillinam: 400mg three times daily for 3-5 days 1

Alternative treatments:

• Cephalosporins (e.g., cefadroxil): 500mg twice daily for 3 days (if local E. coli resistance <20%) 1
• Trimethoprim: 200mg twice daily for 5 days (not in first trimester of pregnancy) 1
• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days (not in last trimester of pregnancy) 1, 2

Treatment in men:

• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1
• Fluoroquinolones can be prescribed according to local susceptibility testing 1

Management Considerations

• For women with mild to moderate symptoms, symptomatic therapy (e.g., ibuprofen) may be considered as an alternative to antimicrobial treatment in consultation with individual patients 1
• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1
• For women whose symptoms don't resolve by end of treatment or recur within 2 weeks, obtain urine culture and antimicrobial susceptibility testing 1
• For retreatment, assume the infecting organism is not susceptible to the original agent and use a 7-day regimen with another agent 1

Recurrent UTIs

Recurrent UTIs are defined as at least three UTIs/year or two UTIs in the last 6 months 1

Prevention strategies (in order of recommendation):

1. Non-antimicrobial interventions:

   • Increased fluid intake for premenopausal women (weak recommendation) 1
   • Vaginal estrogen replacement for postmenopausal women (strong recommendation) 1
   • Immunoactive prophylaxis (strong recommendation) 1
   • Methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 1
   • Consider probiotics, cranberry products, or D-mannose (weak recommendations) 1

2. Antimicrobial prophylaxis:

   • Use continuous or postcoital antimicrobial prophylaxis when non-antimicrobial interventions have failed (strong recommendation) 1
   • For patients with good compliance, self-administered short-term antimicrobial therapy can be considered (strong recommendation) 1

Special Considerations

Asymptomatic Bacteriuria

• Do not treat asymptomatic bacteriuria in non-pregnant patients (strong recommendation) 1
• Omit surveillance urine testing in asymptomatic patients with recurrent UTIs (moderate recommendation) 1

Antibiotic Stewardship

• Choose antimicrobial therapy based on:
  • Spectrum and susceptibility patterns of pathogens
  • Efficacy in clinical studies
  • Tolerability and adverse reactions
  • Adverse ecological effects
  • Costs and availability 1
• Use first-line agents (nitrofurantoin, TMP-SMX, fosfomycin) to minimize "collateral damage" and antimicrobial resistance 1, 3
• Treat acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than seven days 1

Pyelonephritis

• Uncomplicated pyelonephritis presents with fever (>38°C), chills, flank pain, nausea, vomiting, or tenderness at costovertebral angle 1
• Third-generation cephalosporins are preferred for management 4
• For pregnant patients with pyelonephritis, hospitalization and intravenous antibiotics are indicated 4

Common Pitfalls to Avoid

• Treating asymptomatic bacteriuria (except in pregnancy or before invasive urinary procedures) 1
• Using fluoroquinolones as first-line therapy for uncomplicated cystitis (reserve for more invasive infections) 5
• Failing to obtain cultures in patients with recurrent or non-resolving symptoms 1
• Overuse of broad-spectrum antibiotics, which can lead to increased resistance 3, 6
• Inadequate treatment duration, which can lead to persistent infection 1