What is the treatment for urinary tract infections (UTIs)?

Treatment of Urinary Tract Infections (UTIs)

For uncomplicated UTIs in women, first-line treatment includes nitrofurantoin 100 mg twice daily for 5 days, fosfomycin 3 g single dose, or trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (if local resistance <20%). 1, 2

Acute Treatment Algorithm

First-Line Options:

• Nitrofurantoin 100 mg twice daily for 5 days (preferred due to low resistance rates) 1, 2
• Fosfomycin trometamol 3 g single dose 1, 2
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (only if local resistance <20%) 1, 3

Second-Line Options (when first-line cannot be used):

• Oral cephalosporins such as cephalexin 2
• Amoxicillin-clavulanate 2, 4
• Avoid fluoroquinolones due to FDA warning about serious adverse effects and unfavorable risk-benefit ratio 5, 1

Management of Recurrent UTIs

Definition:

• Recurrent UTI (rUTI) is defined as ≥2 symptomatic episodes in 6 months or ≥3 episodes in 1 year 5

Prevention Strategies:

Non-Antibiotic Approaches (First-Line):

• Behavioral modifications: adequate hydration, voiding after intercourse, avoiding prolonged holding of urine 5
• For postmenopausal women: vaginal estrogen therapy with or without lactobacillus-containing probiotics 5, 1
• Methenamine hippurate as a non-antibiotic preventive option 5, 1
• Lactobacillus-containing probiotics to restore normal vaginal flora 5, 1
• Avoid disrupting normal vaginal flora with spermicides or harsh cleansers 5

Antibiotic Prophylaxis (when non-antibiotic approaches fail):

• For premenopausal women with post-coital infections: low-dose antibiotic within 2 hours of sexual activity 5, 1
• For premenopausal women with infections unrelated to sexual activity: low-dose daily antibiotic prophylaxis 5
• Recommended prophylactic antibiotics:
  • Nitrofurantoin 50-100 mg daily (preferred due to low resistance) 5, 1
  • Trimethoprim-sulfamethoxazole 40/200 mg daily 5
  • Rotate antibiotics every 3 months to avoid resistance development 5

Important Clinical Considerations

Before Starting Treatment:

• Confirm diagnosis with urine culture before initiating treatment to guide appropriate antibiotic selection 1
• Evaluate for complicating factors that may require additional testing (structural abnormalities, diabetes, immunosuppression) 5, 1

Common Pitfalls to Avoid:

• Do not treat asymptomatic bacteriuria as this increases antimicrobial resistance and risk of symptomatic UTIs 5, 1
• Avoid prolonged antibiotic courses (>5 days), broad-spectrum or unnecessary antibiotics 5
• Do not classify recurrent UTIs as "complicated" solely based on recurrence, as this often leads to unnecessary use of broad-spectrum antibiotics 5, 1
• Avoid fluoroquinolones for uncomplicated UTIs due to high resistance rates and serious adverse effects 5, 1

Follow-up:

• If symptoms persist despite treatment, repeat urine culture to assess for ongoing bacteriuria before prescribing additional antibiotics 1
• If symptoms recur rapidly (within 2 weeks) with the same organism, consider evaluation for anatomical abnormalities 1
• Urine culture is not needed after successful treatment (symptom resolution) 1

Special Considerations for Antimicrobial Stewardship

• Select antibiotics based on local resistance patterns and patient-specific factors 5, 2
• Use shortest effective duration of antibiotics (typically 3-5 days for uncomplicated UTIs) 5, 2
• Consider antibiotic resistance when selecting empiric therapy; nitrofurantoin resistance remains low and decays quickly if it develops 5, 1