What are the recommended treatments for uncomplicated and complicated urinary tract infections (UTIs)?

Treatment of Urinary Tract Infections (UTIs)

For uncomplicated and complicated UTIs, first-line treatments include fosfomycin trometamol, nitrofurantoin, and pivmecillinam for uncomplicated cases, while fluoroquinolones, cephalosporins, and aminoglycosides are recommended for complicated infections, with treatment choices guided by local resistance patterns. 1, 2

Uncomplicated UTIs in Women

First-line Treatment Options

• Fosfomycin trometamol 3g as a single dose is highly effective with minimal resistance and low potential for collateral damage 1, 2
• Nitrofurantoin 100mg twice daily for 5 days (or macrocrystals 50-100mg four times daily) is recommended due to sustained effectiveness and low resistance rates 1, 2
• Pivmecillinam 400mg three times daily for 3-5 days is appropriate where available (primarily in European countries) 1, 2

Alternative Treatment Options

• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days if local resistance rates are <20% (not recommended in last trimester of pregnancy) 1, 3
• Trimethoprim 200mg twice daily for 5 days (avoid in first trimester of pregnancy) 1
• Cephalosporins (e.g., cefadroxil 500mg twice daily for 3 days) if local E. coli resistance is <20% 1, 2
• Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) are effective but should be reserved for more serious infections due to their propensity for collateral damage 1, 4

Treatment Duration

• Single dose: Fosfomycin trometamol 1
• 3-day regimens: Trimethoprim-sulfamethoxazole, some cephalosporins 1
• 5-day regimens: Nitrofurantoin, trimethoprim, pivmecillinam 1, 2

Uncomplicated UTIs in Men

• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 7 days is the primary treatment 1, 2
• Fluoroquinolones can be prescribed according to local susceptibility patterns 1, 2
• Longer treatment duration (7 days) is typically recommended for men 1, 3

Complicated UTIs and Pyelonephritis

Outpatient Treatment

• Oral ciprofloxacin 500mg twice daily for 7 days is appropriate when fluoroquinolone resistance is <10% 1
• Extended-release ciprofloxacin 1000mg daily for 7 days or levofloxacin 750mg daily for 5 days are effective options 1
• Consider an initial IV dose of ceftriaxone 1g or a 24-hour dose of an aminoglycoside if fluoroquinolone resistance exceeds 10% 1
• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 14 days if the pathogen is known to be susceptible 1

Inpatient Treatment

• Initial IV therapy with one of the following 1:
  • Fluoroquinolone (if local resistance <10%)
  • Aminoglycoside with or without ampicillin
  • Extended-spectrum cephalosporin or penicillin (with or without aminoglycoside)
  • Carbapenem
• Treatment should be tailored based on culture and susceptibility results 1

Special Considerations

Recurrent UTIs

• Always obtain a urine culture for diagnosis 1, 2
• For women whose symptoms don't resolve by the end of treatment or recur within 2 weeks, perform urine culture and susceptibility testing 1
• Retreatment with a 7-day regimen using a different agent is recommended for recurrence 1

Antimicrobial Resistance Concerns

• Local resistance patterns should guide empiric therapy choices 1
• Escherichia coli is the predominant pathogen (75-95%) in uncomplicated UTIs 1
• Amoxicillin or ampicillin should not be used for empirical treatment due to poor efficacy and high worldwide resistance 1
• β-lactams (except pivmecillinam) generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials 1, 5

Diagnostic Approach

• Diagnosis of uncomplicated cystitis can be made with high probability based on symptoms (dysuria, frequency, urgency) and absence of vaginal discharge 1
• Urine culture is recommended for suspected pyelonephritis, symptoms that don't resolve or recur within 4 weeks after treatment, women with atypical symptoms, and pregnant women 1
• For typical uncomplicated cystitis, urine analysis provides minimal increase in diagnostic accuracy 1

Treatment Algorithm

1. Assess if uncomplicated or complicated UTI:

   • Uncomplicated: Healthy non-pregnant women with no urological abnormalities
   • Complicated: Men, pregnant women, urological abnormalities, immunocompromise, or systemic symptoms

2. For uncomplicated UTI in women:

   • First choice: Fosfomycin 3g single dose, nitrofurantoin 100mg BID for 5 days, or pivmecillinam 400mg TID for 3-5 days 1, 2
   • Second choice: Trimethoprim-sulfamethoxazole 160/800mg BID for 3 days (if local resistance <20%) 1

3. For uncomplicated UTI in men:

   • Trimethoprim-sulfamethoxazole 160/800mg BID for 7 days 1, 2
   • Fluoroquinolones based on local susceptibility 1, 2

4. For complicated UTI/pyelonephritis:

   • Outpatient: Ciprofloxacin 500mg BID for 7 days or levofloxacin 750mg daily for 5 days 1
   • Consider initial IV dose of ceftriaxone 1g if fluoroquinolone resistance >10% 1
   • Inpatient: IV therapy based on local resistance patterns 1

5. For recurrent UTI:

   • Always obtain urine culture 1, 2
   • Use different agent than previous treatment for 7 days 1
   • Consider prophylactic strategies for frequent recurrences 2, 3

Common Pitfalls and Caveats

• Fluoroquinolones should be reserved for more serious infections due to risk of collateral damage and increasing resistance 1, 5
• β-lactams (except pivmecillinam) should be used with caution due to inferior efficacy 1
• Routine post-treatment urinalysis or cultures are not indicated for asymptomatic patients 1
• Local resistance patterns significantly impact treatment success - what works in one region may not work in another 1, 6
• In elderly patients, genitourinary symptoms are not necessarily related to cystitis 1