How many days should a patient take antibiotics for an uncomplicated urinary tract infection?

Duration of Antibiotic Treatment for Urinary Tract Infections

For uncomplicated urinary tract infections, the recommended antibiotic duration depends on the specific antibiotic used: nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days, or fosfomycin as a single dose. 1

Treatment Duration Based on UTI Type

Uncomplicated Cystitis in Women

• Nitrofurantoin: 5-day course 1
• TMP-SMX: 3-day course 1
• Fosfomycin: single dose 1
• Fluoroquinolones: 3-day regimens are effective but should be reserved for patients with history of resistant organisms due to high propensity for adverse effects 1

Uncomplicated Pyelonephritis

• Fluoroquinolones: 5-7 days (based on recent evidence showing 5-day course is noninferior to 10-day course) 1
• TMP-SMX: 14 days (when susceptibility is confirmed) 1

Catheter-Associated UTI (CA-UTI)

• Standard duration: 7 days for patients with prompt symptom resolution 1
• Extended duration: 10-14 days for those with delayed response 1
• Levofloxacin: 5-day regimen may be considered for patients who are not severely ill 1
• For women ≤65 years with CA-UTI without upper tract symptoms after catheter removal: 3-day regimen may be considered 1

Antibiotic Selection Considerations

• Escherichia coli accounts for >75% of all bacterial cystitis, so empirical antibiotics should target this organism 1
• For pyelonephritis, fluoroquinolones should not be used empirically without culture and susceptibility testing due to increasing resistance rates 1
• TMP-SMX should not be used empirically for pyelonephritis without culture and susceptibility testing due to high resistance rates 1

Special Considerations

• Shorter durations of treatment are preferred when appropriate to limit development of resistance 1
• For complicated UTIs or those with structural/functional abnormalities of the genitourinary tract, longer treatment courses may be necessary 1
• Treatment may need to be extended if the patient does not have a prompt clinical response with defervescence by 72 hours 1

Common Pitfalls to Avoid

• Using fluoroquinolones as first-line empiric therapy despite their efficacy due to high risk of adverse effects and increasing resistance 1, 2
• Treating for longer than necessary, which increases risk of antibiotic-associated adverse events without additional benefits 1
• Using TMP-SMX empirically for pyelonephritis without confirming susceptibility 1
• Not adjusting treatment based on culture and susceptibility results 1
• Failing to discontinue urinary catheters as soon as appropriate, which can prolong infection 1

Evidence Quality and Recent Developments

• Recent randomized controlled trials have shown that 5-day courses of fluoroquinolones are noninferior to 10-day courses for pyelonephritis, with clinical cure rates above 93% 1
• A recent study found that a 7-day course of TMP-SMX may be effective for women with susceptible E. coli pyelonephritis compared with a 7-day course of ciprofloxacin 1
• The 2021 American College of Physicians guidelines provide the most recent evidence-based recommendations for short-course antibiotic therapy in common infections, including UTIs 1