What are the recommended treatments for uncomplicated and complicated urinary tract infections (UTIs)?

Treatment of Urinary Tract Infections (UTIs)

For uncomplicated and complicated UTIs, first-line treatments include fosfomycin trometamol, nitrofurantoin, and pivmecillinam for women, while trimethoprim-sulfamethoxazole is recommended for men. 1

Uncomplicated UTIs

Diagnosis

• Diagnosis of uncomplicated cystitis can be made based on focused history of lower urinary tract symptoms (dysuria, frequency, urgency) and absence of vaginal discharge 1
• Urine culture is not necessary for typical presentations but recommended in cases of:
  • Suspected pyelonephritis
  • Symptoms that don't resolve or recur within 4 weeks after treatment
  • Women with atypical symptoms
  • Pregnant women 1

First-line Treatment Options for Women

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

Alternative Treatment Options for Women

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

Treatment for Men

• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1
• Fluoroquinolones can be prescribed according to local susceptibility testing 1

Important Considerations

• Fluoroquinolones (ciprofloxacin, levofloxacin) are highly efficacious but should be reserved for important uses other than acute cystitis due to their propensity for collateral damage 1
• β-Lactams (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) should be used with caution due to inferior efficacy and more adverse effects 1
• Amoxicillin or ampicillin should not be used for empirical treatment due to poor efficacy and high resistance rates 1
• For women with mild to moderate symptoms, symptomatic therapy (e.g., ibuprofen) may be considered as an alternative to antimicrobial treatment 1, 2

Complicated UTIs and Pyelonephritis

Pyelonephritis Treatment

• Urine culture and susceptibility testing should always be performed 1
• For outpatient treatment:
  • Oral ciprofloxacin: 500mg twice daily for 7 days (if local resistance <10%) 1
  • Once-daily oral fluoroquinolones: ciprofloxacin 1000mg extended release for 7 days or levofloxacin 750mg for 5 days (if local resistance <10%) 1
  • Consider initial IV dose of long-acting antimicrobial (1g ceftriaxone or 24-hour dose of aminoglycoside) if fluoroquinolone resistance exceeds 10% 1
• For hospitalized patients:
  • Initial IV antimicrobial regimen: fluoroquinolone, aminoglycoside (with/without ampicillin), extended-spectrum cephalosporin/penicillin (with/without aminoglycoside), or carbapenem 1
  • Choice should be based on local resistance data and tailored based on susceptibility results 1

Recurrent UTIs

Definition and Management

• Recurrent UTIs: at least three UTIs/year or two UTIs in last 6 months 1
• Diagnose via urine culture 1
• Non-antimicrobial prevention strategies:
  • Increased fluid intake for premenopausal women 1
  • Vaginal estrogen replacement in postmenopausal women 1
  • Immunoactive prophylaxis 1
  • Methenamine hippurate 1
  • Consider probiotics, cranberry products, and D-mannose (though evidence is weaker) 1
• Antimicrobial prophylaxis when non-antimicrobial interventions fail 1
• Self-administered short-term antimicrobial therapy for patients with good compliance 1

Special Considerations

Antimicrobial Resistance

• Local resistance patterns should guide empiric therapy 1
• Nitrofurantoin, fosfomycin, and mecillinam generally maintain good activity against resistant pathogens 1
• For E. coli in single episodes of UTI, resistance rates are typically <15% for recommended antibiotics 3
• In recurrent UTIs, resistance rates for trimethoprim (21.4%) and cotrimoxazole (19.3%) may exceed the recommended threshold 3

Treatment Failure

• For women whose symptoms don't resolve by end of treatment or recur within 2 weeks:
  • Perform urine culture and 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

Elderly Patients

• First-line antibiotics and treatment durations for non-frail elderly patients without relevant comorbidities are the same as for younger adults 2
• Urine culture with susceptibility testing is recommended to adjust antibiotic choice after initial empiric treatment 2