Treatment for Urinary Tract Infections (UTIs)
First-line treatment for uncomplicated UTIs includes nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, with the specific choice dependent on local antibiogram patterns. 1, 2
Classification of UTIs
- UTIs are categorized as uncomplicated or complicated, with treatment approaches differing significantly between these categories 1
- Complicated UTIs occur in patients with host-related factors or urinary tract abnormalities that make infections more challenging to eradicate 1
- Common factors associated with complicated UTIs include urinary tract obstruction, foreign bodies, incomplete voiding, diabetes mellitus, and immunosuppression 1
Diagnostic Approach
- Urinalysis and urine culture should be obtained before initiating treatment to guide antimicrobial therapy 1
- For complicated UTIs, the microbial spectrum is broader than for uncomplicated UTIs, with E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. being common pathogens 1
- Asymptomatic bacteriuria should not be treated except in pregnant women and patients undergoing invasive urological procedures 1, 2
Treatment for Uncomplicated UTIs
Uncomplicated Cystitis
- Nitrofurantoin: 5-day course 1, 2
- TMP-SMX: 3-day course 1, 3
- Fosfomycin: single 3g dose 1, 2
- Pivmecillinam: 3-day course 1, 4
Uncomplicated Pyelonephritis
- Oral fluoroquinolones when local resistance rates are <10% (ciprofloxacin 500-750mg twice daily for 7 days or levofloxacin 750mg daily for 5 days) 2, 5
- For areas with higher fluoroquinolone resistance, an initial dose of parenteral antibiotic (e.g., ceftriaxone) followed by oral therapy is recommended 2
Treatment for Complicated UTIs
Treatment duration is typically 7-14 days (14 days for men when prostatitis cannot be excluded) 1
Empirical therapy options include 1:
- Amoxicillin plus an aminoglycoside
- A second-generation cephalosporin plus an aminoglycoside
- An intravenous third-generation cephalosporin
For multidrug-resistant organisms, treatment should be based on culture results and susceptibility patterns 1, 4
Duration should be determined based on anatomical location and clinical severity, provided the antimicrobial has activity against the organism 1
Special Populations
Pediatric Patients
- For febrile UTIs in children 2-24 months, antimicrobials effective against common uropathogens should be used according to local sensitivity patterns 1
- Treatment duration for pediatric UTIs is typically 7-14 days 1
Pregnant Women
- Asymptomatic bacteriuria in pregnancy should be treated for 3-5 days depending on the antimicrobial used 2
Catheter-Associated UTIs
- Catheter-associated UTIs are the leading cause of secondary healthcare-associated bacteremia 1
- Treatment should be based on culture results, with consideration of removing or changing the catheter when possible 1
Antimicrobial Stewardship Considerations
- Deescalation of antibiotics is strongly recommended when culture results become available 1, 2
- Oral regimens are preferred over intravenous when possible, as they show comparable outcomes while reducing hospital length of stay and adverse events 1, 2
- Use of fluoroquinolones should be restricted due to increasing resistance rates 4, 6
Prevention of Recurrent UTIs
- Increased fluid intake may reduce risk of recurrent UTIs in premenopausal women 2
- Vaginal estrogen replacement is recommended for postmenopausal women to prevent recurrent UTIs 2
- Methenamine hippurate can reduce recurrent UTI episodes in women without urinary tract abnormalities 2
Common Pitfalls to Avoid
- Treating asymptomatic bacteriuria (except in pregnancy or before urological procedures) 1, 2
- Using fluoroquinolones as first-line empiric therapy in areas with high resistance rates 4, 6
- Failing to adjust antimicrobial therapy based on culture results 1
- Not addressing underlying anatomical or functional abnormalities in complicated UTIs 1, 7