Treatment for Uncomplicated vs Complicated UTIs
For uncomplicated UTIs, first-line treatment options include nitrofurantoin, fosfomycin, or trimethoprim-sulfamethoxazole (if local resistance <20%), while complicated UTIs require broader coverage with fluoroquinolones or parenteral antibiotics based on culture results and severity. 1
Uncomplicated UTIs
Definition
- Bacterial infection of the lower urinary tract with no systemic illness in a non-pregnant adult with normal urinary tract anatomy and no immunocompromise 2
- Typically seen in premenopausal, non-pregnant women with no known urological abnormalities or comorbidities 1
First-line Treatment Options
Nitrofurantoin monohydrate/macrocrystals: 100 mg twice daily for 5 days 1
- Minimal resistance and low propensity for collateral damage
- Avoid if early pyelonephritis suspected
Fosfomycin trometamol: 3 g single dose 1
- Convenient single-dose regimen
- Slightly lower efficacy than other first-line agents
- Avoid if early pyelonephritis suspected
Trimethoprim-sulfamethoxazole: 160/800 mg (one double-strength tablet) twice daily for 3 days 1, 3
- Use only if local resistance rates <20% or if the infecting strain is known to be susceptible
- Avoid if used for UTI in previous 3 months
Pivmecillinam: 400 mg twice daily for 5 days (not available in all countries) 1
- Lower efficacy than some other recommended agents
- Avoid if early pyelonephritis suspected
Duration of Therapy
- Treat for shortest effective duration, generally 3-5 days for uncomplicated cystitis 1, 2
- Men with uncomplicated UTI should receive 7 days of treatment 1, 2
Complicated UTIs
Definition
- UTIs occurring in patients with functional or structural abnormalities of the urinary tract, or with underlying diseases that increase risk of acquiring infection or treatment failure 4
- Includes pyelonephritis, UTIs in men, pregnant women, patients with indwelling catheters, urinary tract obstruction, renal failure, or immunosuppression 1, 4
Treatment Approach
- Obtain urine culture and susceptibility testing before initiating antibiotics 1, 5
- Initial empiric therapy should be based on severity, risk factors, and local resistance patterns 4
Antibiotic Options for Complicated UTIs
Fluoroquinolones (e.g., ciprofloxacin): First-line for oral treatment of uncomplicated pyelonephritis due to efficacy, but use with caution due to increasing resistance and collateral damage 1, 6
- Ciprofloxacin 500 mg twice daily for 7-14 days depending on severity
Parenteral antibiotics: For severe infections, sepsis, or inability to tolerate oral medications 4
- Options include third-generation cephalosporins, aminoglycosides, or carbapenems
- Duration typically 7-14 days based on severity and response
Culture-directed therapy: Adjust based on susceptibility results 1, 4
- For resistant organisms, consult infectious disease specialists
Special Considerations
Recurrent UTIs
- Defined as ≥3 UTIs per year or ≥2 UTIs in 6 months 1, 5
- Obtain urine culture with each symptomatic episode 1, 5
- Consider patient-initiated treatment (self-start) for select patients 1
- Preventive strategies include increased fluid intake, vaginal estrogen in postmenopausal women, and immunoactive prophylaxis 1, 5
Asymptomatic Bacteriuria
- Do not screen for or treat asymptomatic bacteriuria except in pregnant women or before invasive urologic procedures 1
- Treatment of asymptomatic bacteriuria increases risk of antimicrobial resistance 5
Common Pitfalls to Avoid
- Using fluoroquinolones as first-line for uncomplicated cystitis due to increasing resistance and collateral damage 1, 7
- Treating for longer than necessary, which increases risk of adverse effects and resistance 1, 2
- Failing to obtain cultures in complicated or recurrent cases 1, 5
- Using broad-spectrum antibiotics when narrow-spectrum options are appropriate 4, 7
- Treating asymptomatic bacteriuria 1, 5