What are the treatment options for urinary tract infections (UTIs)?

Treatment Options for Urinary Tract Infections

First-line treatment for uncomplicated urinary tract infections should be nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, depending on local antibiogram patterns, with treatment duration of 3-5 days for most cases. 1

Classification of UTIs

• UTIs are classified as uncomplicated or complicated based on patient factors and presence of structural/functional abnormalities in the urinary tract 1
• Complicated UTIs occur when host-related factors or specific anatomic/functional abnormalities make the infection more difficult to eradicate 2
• Common factors associated with complicated UTIs include obstruction, foreign bodies, incomplete voiding, vesicoureteral reflux, recent instrumentation, male gender, pregnancy, diabetes, and immunosuppression 2

First-Line Treatment for Uncomplicated UTIs

• Nitrofurantoin: 5-day course (clear recommendation) 2, 1
• Trimethoprim-sulfamethoxazole (TMP-SMX): 3-day course (clear recommendation) 2, 1, 3
• Fosfomycin: Single dose (clear recommendation) 2, 1
• Pivmecillinam: 3-day course (clear recommendation) 2, 4
• Beta-lactams are considered second-line options due to inferior efficacy and higher rates of side effects 1, 4

Treatment for Complicated UTIs

• For complicated UTIs, treatment duration is typically 7-14 days 2, 1
• Recommended empirical regimens include 2:
  • Amoxicillin plus an aminoglycoside
  • A second-generation cephalosporin plus an aminoglycoside
  • An intravenous third-generation cephalosporin
• Ceftriaxone is recommended for patients requiring intravenous therapy without risk factors for multidrug resistance 2
• Therapy should be tailored based on urine culture results and local resistance patterns 2, 1

Special Populations

Pregnant Women

• Asymptomatic bacteriuria should be treated in pregnant women 2, 1
• Treatment duration should not exceed that used for symptomatic cystitis (3-5 days) 2

Catheter-Associated UTIs (CAUTIs)

• Replace or discontinue existing catheters prior to collecting cultures and initiating treatment when possible 2
• Empirical treatment should consider the patient's urinary tract anatomy, allergies, prior microbiological history, and clinical severity 2
• Signs of CAUTI include new onset of fever, rigors, altered mental status, malaise, flank pain, and pelvic discomfort 2

Multidrug-Resistant Organisms (MDROs)

• Risk factors for MDROs include prior healthcare exposure, previous antibiotic use, and history of UTI or known colonization 2
• Treatment duration for MDROs should be determined based on anatomical location and clinical severity, similar to non-resistant organisms 2
• Ensure the chosen antimicrobial has demonstrated activity against the organism and efficacy for UTI treatment 2

Prevention of Recurrent UTIs

• For postmenopausal women: Consider vaginal estrogen with or without lactobacillus-containing probiotics 2, 1
• For premenopausal women with post-coital infections: Consider low-dose antibiotic prophylaxis within 2 hours of sexual activity 2, 1
• Daily antibiotic prophylaxis (particularly nitrofurantoin) is the most effective strategy for preventing recurrent UTIs 2, 1
• Non-antibiotic alternatives include methenamine hippurate and lactobacillus-containing probiotics 2, 1

Antimicrobial Stewardship Considerations

• Obtain urine cultures before starting antibiotics to guide appropriate therapy 1
• De-escalate to narrower spectrum antibiotics based on culture results 2
• Oral regimens are as effective as intravenous-only treatment for many UTIs and may reduce hospital length of stay and adverse events 2
• Avoid treating asymptomatic bacteriuria except in pregnant women and patients undergoing invasive urologic procedures 2, 1

Common Pitfalls to Avoid

• Using fluoroquinolones as first-line empiric therapy due to increasing resistance rates and potential adverse effects 1, 5
• Treating asymptomatic bacteriuria in non-pregnant patients, which increases antimicrobial resistance without clinical benefit 2, 1
• Using nitrofurantoin for suspected pyelonephritis or urosepsis (inadequate tissue/blood levels) 1, 4
• Misclassifying patients with recurrent UTIs as having "complicated" UTIs, which often leads to unnecessary use of broad-spectrum antibiotics 2