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

Treatment of Uncomplicated Urinary Tract Infections

First-line treatment for uncomplicated UTI in women includes nitrofurantoin (5-day course), fosfomycin trometamol (single 3g dose), or trimethoprim-sulfamethoxazole (3-day course) based on local antibiogram patterns. 1, 2

Diagnosis and Assessment

• Diagnosis of uncomplicated cystitis can be made with high probability based on typical lower urinary tract symptoms (dysuria, frequency, urgency) and absence of vaginal discharge 1
• Urine culture is not routinely needed for uncomplicated UTI with typical symptoms but should be obtained in the following situations 1, 2:
  • Suspected acute pyelonephritis
  • Symptoms that do not resolve or recur within 4 weeks after treatment
  • Women presenting with atypical symptoms
  • Pregnant women

First-Line Antibiotic Treatment Options

Nitrofurantoin

• Dosage: 100 mg twice daily or 50-100 mg four times daily for 5 days 1, 2
• Advantages: Low resistance rates, minimal impact on normal flora 2, 3
• Contraindications: Renal insufficiency (CrCl <30 mL/min) 2

Fosfomycin Trometamol

• Dosage: Single 3g dose 1, 4
• Advantages: Convenient single-dose regimen, good activity against resistant pathogens 4, 5
• FDA approved specifically for uncomplicated UTIs in women 4

Trimethoprim-Sulfamethoxazole (TMP-SMX)

• Dosage: 160/800 mg twice daily for 3 days 1, 6
• Use only when local E. coli resistance is <20% 1, 2
• Not recommended in first trimester of pregnancy 1

Treatment Duration

• Short courses are preferred to minimize adverse effects and resistance development 1, 2
• Nitrofurantoin: 5 days 1, 2
• Fosfomycin: Single dose 1, 4
• TMP-SMX: 3 days 1, 6
• Avoid single-dose regimens (except fosfomycin) as they have higher rates of bacteriological persistence 1

Alternative Treatment Options

• Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) if local E. coli resistance is <20% 1
• Pivmecillinam 400 mg three times daily for 3-5 days (where available) 1, 7
• Trimethoprim 200 mg twice daily for 5 days 1

Special Considerations

Antimicrobial Stewardship

• Consider local antibiogram patterns when selecting empiric therapy 1, 2
• Avoid fluoroquinolones as first-line agents due to unfavorable risk-benefit ratio and potential for collateral damage 2, 3
• Select antimicrobials with minimal impact on normal vaginal and fecal flora 2

Treatment Failure

• For women whose symptoms do not resolve by the end of treatment or recur within 2 weeks, obtain urine culture with susceptibility testing 1
• Assume the infecting organism is not susceptible to the agent originally used 1
• Retreatment with a 7-day regimen using another agent should be considered 1
• For cultures showing resistance to oral antibiotics, culture-directed parenteral antibiotics may be needed for up to 7 days 1

Asymptomatic Bacteriuria

• Do not perform surveillance urine testing in asymptomatic patients 1, 2
• Do not treat asymptomatic bacteriuria except in pregnant women and patients scheduled for invasive urinary tract procedures 1, 2

Recurrent UTIs

• Consider antibiotic prophylaxis for patients with recurrent UTIs after discussing risks, benefits, and alternatives 1, 2
• Non-antibiotic preventive measures include increased fluid intake, vaginal estrogen in postmenopausal women, and immunoactive prophylaxis 1
• Methenamine hippurate can be used to reduce recurrent UTI episodes in women without urinary tract abnormalities 1

Common Pitfalls and Caveats

• Treating asymptomatic bacteriuria increases risk of symptomatic infection, bacterial resistance, and healthcare costs 2
• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1
• Increasing resistance to TMP-SMX worldwide necessitates awareness of local resistance patterns 3, 8
• For cultures showing resistance to multiple antibiotics, fosfomycin remains active against many ESBL-producing E. coli strains 3, 5