What is the treatment for a patient presenting with signs and symptoms of a urinary tract infection (UTI)?

Treatment of Urinary Tract Infections

First-line treatment for uncomplicated UTI should include nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, with antibiotic selection based on local resistance patterns. 1, 2

Diagnosis of UTI

• Acute-onset symptoms of UTI typically include dysuria, frequency, urgency, hematuria, and new or worsening incontinence, with dysuria being central to the diagnosis 1
• In women without vaginal discharge, a self-diagnosis of UTI with typical symptoms is accurate enough to diagnose an uncomplicated UTI without further testing 2
• Urinalysis and urine culture should be obtained prior to initiating treatment in patients with suspected UTI to confirm diagnosis and guide appropriate antibiotic therapy 1
• Urine culture is particularly important for:
  • Recurrent infections
  • Treatment failures
  • History of resistant isolates
  • Atypical presentations
  • Suspected complicated UTIs 2, 3

Treatment Recommendations for Uncomplicated UTI

First-line Antibiotic Options:

• Nitrofurantoin for 5 days 1, 2
• Trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days (if local resistance <20%) 1, 4, 3
• Fosfomycin as a single dose 2, 5

Treatment Duration:

• As short a duration as reasonable, generally no longer than 7 days 1
• 3-5 days is typically sufficient for uncomplicated cystitis in women 2, 6
• 7 days for men with uncomplicated UTI 2

Patient-Initiated Treatment:

• Self-start treatment may be offered to select patients with recurrent UTIs while awaiting urine culture results 1
• This approach allows for prompt symptom relief while ensuring appropriate antimicrobial stewardship 1

Special Considerations

Complicated UTIs

• Complicated UTIs occur in patients with structural or functional abnormalities of the urinary tract, immunosuppression, pregnancy, or other complicating factors 1, 6
• Treatment options for complicated UTIs with systemic symptoms include:
  • Amoxicillin plus an aminoglycoside
  • A second-generation cephalosporin plus an aminoglycoside
  • An intravenous third-generation cephalosporin 1
• Treatment duration is typically 7-14 days, with 14 days for men when prostatitis cannot be excluded 1

Antimicrobial Stewardship

• Local resistance patterns should guide antibiotic selection 1
• Fluoroquinolones (e.g., ciprofloxacin) should be reserved as second-line agents due to increasing resistance and risk of collateral damage 1, 7, 5
• Only use ciprofloxacin if local resistance is <10% and:
  • The entire treatment is given orally
  • The patient does not require hospitalization
  • The patient has anaphylaxis to β-lactam antimicrobials 1

Asymptomatic Bacteriuria

• Asymptomatic bacteriuria should not be treated with antibiotics 1
• Surveillance urine testing should be omitted in asymptomatic patients 1
• Exceptions for treatment include pregnancy and prior to urological procedures breaching the mucosa 1

Non-Antibiotic Approaches

• Symptomatic treatment with NSAIDs and delayed antibiotics may be considered in mild to moderate cases 1, 2
• For recurrent UTIs, preventive strategies include:
  • Increased fluid intake
  • Cranberry products
  • Methenamine hippurate 2

Common Pitfalls and Caveats

• Overtreatment of asymptomatic bacteriuria leads to unnecessary antibiotic use and increased resistance 1
• Failure to obtain cultures before initiating antibiotics can lead to inappropriate treatment and missed diagnoses 1
• Persistent symptoms after treatment warrant further evaluation for resistant organisms or alternative diagnoses 8
• Virtual encounters for UTI management without laboratory testing may increase recurrent symptoms and antibiotic courses 8
• Consider alternative diagnoses in women with dysuria and vaginal discharge, as this decreases the likelihood of UTI 8, 3