What is the treatment for an uncomplicated urinary tract infection (UTI)?

Treatment of Uncomplicated Urinary Tract Infections

First-line treatment for uncomplicated UTIs should be nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, depending on local antibiogram patterns, with treatment duration generally no longer than 7 days. 1

Diagnosis and Initial Assessment

• Obtain urinalysis and urine culture with sensitivity testing prior to initiating treatment to confirm diagnosis and guide appropriate antibiotic selection 1
• Self-diagnosis by women with typical symptoms (dysuria, frequency, urgency, nocturia, suprapubic pain) without vaginal discharge is often accurate enough to diagnose uncomplicated UTI 2
• Patient-initiated treatment may be offered to select patients with recurrent UTIs while awaiting culture results 1

First-Line Antibiotic Treatment

• Nitrofurantoin: 5-day course (50-100 mg four times daily) 1, 2
• Trimethoprim-sulfamethoxazole (TMP-SMX): 3-day course (dependent on local resistance patterns being <20%) 1, 3, 2
• Fosfomycin trometamol: Single 3g dose 1, 2

Treatment Duration

• Treat with as short a duration of antibiotics as reasonable, generally no longer than 7 days 1
• Single-dose antibiotics (except fosfomycin) have been associated with higher rates of bacteriological persistence compared to short-course (3-6 days) or longer-course (7-14 days) therapy 1

Special Considerations

• For cultures showing resistance to oral antibiotics, culture-directed parenteral antibiotics may be used for as short a course as reasonable, generally no longer than 7 days 1
• Avoid fluoroquinolones as first-line agents due to:
  • FDA advisory warning against their use in uncomplicated UTIs due to unfavorable risk-benefit ratio 1
  • Potential for collateral damage to normal flora 1
  • Increasing resistance rates 1, 4

Asymptomatic Bacteriuria

• Do not perform surveillance urine testing in asymptomatic patients with history of recurrent UTIs 1
• Do not treat asymptomatic bacteriuria (ASB) in non-pregnant patients 1
• Exceptions for ASB treatment include pregnant women and patients scheduled for invasive urinary tract procedures 1

Antimicrobial Stewardship

• Consider local antibiogram patterns when selecting empiric therapy 1
• Select antimicrobial agents with the least impact on normal vaginal and fecal flora 1
• Avoid broad-spectrum antibiotics like fluoroquinolones and cephalosporins when possible to minimize "collateral damage" (selection of multi-resistant pathogens) 1, 5

Recurrent UTIs

• For patients with recurrent UTIs, antibiotic prophylaxis may be considered following discussion of risks, benefits, and alternatives 1
• Prophylactic antibiotics have been shown to decrease the risk of future UTIs but may increase adverse events and antimicrobial resistance 1
• The effects of antibiotic prophylaxis last only during the active intake period 1

Common Pitfalls and Caveats

• Failure to obtain cultures before initiating treatment in patients with recurrent UTIs can lead to inappropriate antibiotic selection 1
• Treating asymptomatic bacteriuria increases the risk of symptomatic infection, bacterial resistance, and healthcare costs 1
• Lack of correlation between microbiological data and symptomatic episodes should prompt consideration of alternative diagnoses 1
• Single-dose antibiotic regimens (except fosfomycin) are associated with higher rates of treatment failure 1