What are the guidelines for treating urinary tract infections (UTIs)?

Guidelines for Treating Urinary Tract Infections (UTIs)

First-line treatment for uncomplicated cystitis in women should include fosfomycin trometamol (3g single dose), nitrofurantoin (100mg twice daily for 5 days), or pivmecillinam (400mg three times daily for 3-5 days), based on local resistance patterns. 1

Diagnosis of UTIs

• Diagnosis of uncomplicated cystitis in women can be made based on typical symptoms (frequency, urgency, dysuria, nocturia, suprapubic pain) without vaginal discharge 2
• Urine culture is recommended in the following situations:
  • Suspected acute pyelonephritis 1
  • Symptoms that do not resolve or recur within 4 weeks after treatment 1
  • Women with atypical symptoms 1
  • Pregnant women 1
  • All cases of recurrent UTI 1

Treatment of Uncomplicated Cystitis

First-line treatments for women:

• Fosfomycin trometamol: 3g single dose 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 treatments (when first-line options cannot be used):

• 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

Treatment of Uncomplicated Pyelonephritis

Oral treatment options:

• Ciprofloxacin: 500-750mg twice daily for 7 days 1
• Levofloxacin: 750mg once daily for 5 days 1, 3
• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 14 days 1, 4
• Cefpodoxime: 200mg twice daily for 10 days 1
• Ceftibuten: 400mg once daily for 10 days 1

Parenteral treatment options (for severe cases):

• Initial IV therapy with options including fluoroquinolones, aminoglycosides, extended-spectrum cephalosporins, or penicillins 1
• Switch to oral therapy once clinically improved 1

Management of Recurrent UTIs

Recurrent UTIs are defined as at least three UTIs per year or two UTIs in the last 6 months 1.

Non-antimicrobial prevention strategies (try first):

• Increased fluid intake for premenopausal women 1
• Vaginal estrogen replacement for postmenopausal women (strong recommendation) 1
• Immunoactive prophylaxis (strong recommendation) 1
• Methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 1
• Probiotics with strains of proven efficacy 1
• Cranberry products (weak evidence with contradictory findings) 1
• D-mannose (weak and contradictory evidence) 1

Antimicrobial prophylaxis (when non-antimicrobial interventions have failed):

• Continuous or postcoital antimicrobial prophylaxis 1
• Self-administered short-term antimicrobial therapy for patients with good compliance 1

Treatment of Complicated UTIs

Complicated UTIs occur with host-related factors or anatomic/functional abnormalities 1.

• Treatment duration: 7-14 days (14 days for men when prostatitis cannot be excluded) 1
• Shorter treatment (7 days) may be considered when patient is hemodynamically stable and afebrile for at least 48 hours 1
• Appropriate management of underlying urological abnormality is mandatory 1

Special Considerations

Asymptomatic Bacteriuria

• Should not be treated except in pregnant women or prior to urinary tract procedures 1
• Surveillance urine testing should be omitted in asymptomatic patients with history of recurrent UTIs 1

Elderly Patients

• First-line antibiotics and treatment durations for non-frail elderly patients (≥65 years) without relevant comorbidities are the same as for younger adults 2
• Urine culture with susceptibility testing is necessary to adjust antibiotic choice after initial empiric treatment 2

Common Pitfalls and Caveats

• Fluoroquinolones should be reserved for more invasive infections due to risk of "collateral damage" (selection of multi-resistant pathogens) 1, 5
• For women whose symptoms don't resolve by end of treatment or recur within 2 weeks, perform urine culture and antimicrobial susceptibility testing 1
• For retreatment, assume the infecting organism is not susceptible to the original agent and use a 7-day regimen with another agent 1
• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1
• Consider local resistance patterns when selecting empiric therapy 5, 2