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

Treatment of Uncomplicated Urinary Tract Infections

First-line treatment for uncomplicated urinary tract infections includes nitrofurantoin for 5 days, fosfomycin trometamol as a single dose, or pivmecillinam for 3-5 days, with treatment selection based on local resistance patterns and patient factors. 1, 2

First-Line Antibiotic Options

• Nitrofurantoin macrocrystals (50-100 mg four times daily) or monohydrate/macrocrystals (100 mg twice daily) for 5 days 1, 2
• Fosfomycin trometamol 3 g single dose 1, 2
• Pivmecillinam 400 mg three times daily for 3-5 days (where available) 1

Alternative Antibiotic Options

• Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 3 days (only when local E. coli resistance is <20%) 1, 2, 3
• Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) when local E. coli resistance is <20% 1
• Trimethoprim 200 mg twice daily for 5 days (not in first trimester of pregnancy) 1

Special Considerations

Gender-Specific Treatment

• For men with uncomplicated UTI, a 7-day course of trimethoprim-sulfamethoxazole (160/800 mg twice daily) is recommended 1
• Men should always have urine culture and susceptibility testing to guide antibiotic selection 4

Diagnostic Approach

• In women with typical UTI symptoms (frequency, urgency, dysuria, nocturia, suprapubic pain) without vaginal discharge, clinical diagnosis is sufficient to initiate treatment 4
• Urine culture with sensitivity testing should be obtained in the following situations:
  • Recurrent UTIs 1, 2
  • Treatment failure or symptoms that persist/recur within 4 weeks 1
  • Atypical presentation 1
  • Pregnant women 1
  • History of resistant isolates 4

Treatment Duration

• Short-course therapy is preferred to minimize adverse effects and antimicrobial resistance:
  • Nitrofurantoin: 5 days 1, 2
  • Fosfomycin: single 3g dose 1, 2
  • TMP-SMX: 3 days (for women) 1, 2
  • TMP-SMX: 7 days (for men) 1

Antimicrobial Stewardship Considerations

• Fluoroquinolones should be avoided as first-line agents due to unfavorable risk-benefit ratio and potential for "collateral damage" (selection of multi-resistant pathogens) 2, 5
• Consider local antibiogram patterns when selecting empiric therapy 2
• Select antimicrobial agents with the least impact on normal vaginal and fecal flora 2
• Increasing resistance rates against aminopenicillins, TMP-SMX, and fluoroquinolones should be considered when selecting therapy 6, 5

Follow-up and Treatment Failure

• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1
• For women whose symptoms do not resolve by the end of treatment or recur within 2 weeks:
  • Obtain urine culture and antimicrobial susceptibility testing 1
  • Assume the infecting organism is not susceptible to the original agent 1
  • Retreat with a 7-day regimen using another agent 1

Prevention of Recurrent UTIs

• Increase fluid intake in premenopausal women 1
• Use vaginal estrogen replacement in postmenopausal women 1
• Consider immunoactive prophylaxis 1
• Methenamine hippurate can be used to reduce recurrent UTI episodes in women without urinary tract abnormalities 1, 4
• For patients with good compliance, self-administered short-term antimicrobial therapy can be considered 1
• Continuous or postcoital antimicrobial prophylaxis should be used when non-antimicrobial interventions have failed 1

Common Pitfalls and Caveats

• Single-dose antibiotic regimens (except fosfomycin) are associated with higher rates of treatment failure 2
• Treating asymptomatic bacteriuria increases the risk of symptomatic infection, bacterial resistance, and healthcare costs 2
• TMP-SMX is no longer considered first-line when local resistance rates exceed 20% 7
• Nitrofurantoin shows lower treatment failure rates compared to TMP-SMX in real-world studies 8
• Symptomatic treatment with NSAIDs and delayed antibiotics may be considered in select cases as the risk of complications is low 4