Treatment of Urinary Tract Infections (UTIs)
For uncomplicated and complicated UTIs, first-line treatments include fosfomycin trometamol, nitrofurantoin, and pivmecillinam for uncomplicated cystitis in women, while fluoroquinolones and extended-spectrum antibiotics are recommended for complicated UTIs including pyelonephritis. 1
Uncomplicated UTIs (Cystitis)
First-line Treatment Options for Women
- Fosfomycin trometamol: 3g single dose - recommended only for uncomplicated cystitis in women 1, 2
- 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 Treatment Options
- Cephalosporins (e.g., cefadroxil): 500mg twice daily for 3 days - only if local E. coli resistance is <20% 1
- Trimethoprim: 200mg twice daily for 5 days - avoid in first trimester of pregnancy 1, 3
- Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days - avoid in last trimester of pregnancy and only if local resistance rates are <20% 1, 4
Treatment in Men
- Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1
- Fluoroquinolones can be prescribed based on local susceptibility testing 1
Complicated UTIs (Pyelonephritis)
Outpatient Treatment
- Oral ciprofloxacin: 500mg twice daily for 7 days (if local fluoroquinolone resistance <10%) 1
- Once-daily oral fluoroquinolones: ciprofloxacin 1000mg extended-release for 7 days or levofloxacin 750mg for 5 days (if resistance <10%) 1
- If fluoroquinolone resistance >10%: Initial IV dose of ceftriaxone 1g or a 24-hour dose of aminoglycoside before oral therapy 1
Inpatient Treatment
- Intravenous antimicrobial regimens: fluoroquinolone, aminoglycoside (with or without ampicillin), extended-spectrum cephalosporin, extended-spectrum penicillin (with or without aminoglycoside), or carbapenem 1
- Choice should be based on local resistance patterns and adjusted based on culture results 1
Special Considerations
Diagnostic Approach
- Uncomplicated cystitis can be diagnosed based on symptoms (dysuria, frequency, urgency) without testing in women with typical presentation 1, 5
- Urine culture is recommended for:
Treatment Failures
- For women whose symptoms don't resolve by end of treatment or recur within 2 weeks:
Recurrent UTIs
- Definition: At least 3 UTIs per year or 2 UTIs in the last 6 months 1
- Non-antibiotic prevention options (preferred):
- Increased fluid intake for premenopausal women 1
- Vaginal estrogen replacement for postmenopausal women 1
- Immunoactive prophylaxis 1
- Methenamine hippurate 1
- Probiotics with proven efficacy for vaginal flora regeneration 1
- Cranberry products (evidence is contradictory) 1
- D-mannose (evidence is contradictory) 1
- Antibiotic prophylaxis when non-antimicrobial interventions fail 1
Common Pitfalls and Caveats
- Avoid using amoxicillin or ampicillin for empirical treatment due to poor efficacy and high resistance rates 1
- Beta-lactams generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials 1
- Fluoroquinolones should be reserved for complicated UTIs due to their propensity for collateral damage (ecological adverse effects) 1
- Avoid treating asymptomatic bacteriuria (positive urine culture without symptoms) as this leads to unnecessary antibiotic use 6
- For mild to moderate symptoms in women, symptomatic therapy (e.g., ibuprofen) may be considered as an alternative to antibiotics in consultation with patients 1, 5
- Local resistance patterns should guide empiric antibiotic selection, especially for trimethoprim-sulfamethoxazole where resistance rates vary significantly by region 1
- Post-treatment urinalysis or cultures are not indicated for asymptomatic patients 1