What is the recommended treatment for a urinary tract infection (UTI)?

Treatment Recommendations for Urinary Tract Infections (UTIs)

For uncomplicated UTIs in women, first-line treatment includes nitrofurantoin, fosfomycin trometamol, or trimethoprim-sulfamethoxazole (TMP-SMX) for short durations, with nitrofurantoin being preferred due to its effectiveness and low resistance rates. 1

First-Line Treatment Options for Uncomplicated Cystitis

For Women:

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

For Men:

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

When to Obtain Urine Culture

• Suspected acute pyelonephritis 1
• Symptoms that don't resolve or recur within 4 weeks after treatment 1
• Women with atypical symptoms 1
• Pregnant women 1
• Recurrent UTIs (to confirm diagnosis) 1

Treatment Duration Considerations

• Keep antibiotic treatment as short as reasonable to reduce resistance development 1
• For uncomplicated cystitis: 3-5 days depending on the antibiotic 1
• For complicated UTIs or pyelonephritis: 7-14 days 1
• For men: 7 days of treatment is generally recommended 1

Management of Treatment Failure

• If symptoms don't resolve by the end of treatment or recur within 2 weeks, obtain urine culture and antimicrobial susceptibility testing 1
• Assume the infecting organism is not susceptible to the original agent 1
• Retreat with a 7-day regimen using a different antimicrobial agent 1

Special Considerations

Recurrent UTIs

• Defined as ≥3 UTIs per year or ≥2 UTIs in the last 6 months 1
• Preventive strategies (in order of preference) 1:
  1. Non-antimicrobial measures (increased fluid intake for premenopausal women) 1
  2. Vaginal estrogen replacement for postmenopausal women 1
  3. Immunoactive prophylaxis 1
  4. Methenamine hippurate for women without urinary tract abnormalities 1
  5. Continuous or post-coital antimicrobial prophylaxis when other interventions fail 1

Symptomatic Treatment

• For females 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

Common Pitfalls and Caveats

• Avoid treating asymptomatic bacteriuria: Treatment is not recommended except in pregnant women and patients scheduled for urological procedures 1
• Avoid routine post-treatment testing: Urinalysis or urine cultures are not indicated for asymptomatic patients after treatment 1
• Avoid fluoroquinolones as first-line therapy: Due to risk of individual and ecological collateral damage, these should be reserved for cases where other options cannot be used 1
• Nitrofurantoin contraindications: Should not be used in patients with renal impairment or in the last trimester of pregnancy 3
• Consider local resistance patterns: The choice of empiric therapy should be guided by local antibiograms 1
• Avoid extended treatment courses: Longer courses increase risk of resistance without improving outcomes 1

Nitrofurantoin has shown excellent efficacy against common uropathogens with lower resistance rates compared to other antibiotics, making it a preferred first-line option for uncomplicated UTIs 4, 5, 6. Studies have demonstrated its effectiveness in achieving both symptomatic relief and bacteriological cure 6.