What is the first-line treatment for an uncomplicated urinary tract infection (UTI)?

First-Line Treatment for Uncomplicated Urinary Tract Infections (UTIs)

For uncomplicated urinary tract infections, clinicians should use first-line therapy including nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, depending on local antibiogram patterns. 1

First-Line Treatment Options

• Nitrofurantoin 100 mg twice daily for 5 days is recommended as a first-line therapy by both the Infectious Diseases Society of America (IDSA) and the American Urological Association (AUA) 2
• Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 3 days is an effective alternative when local resistance rates are below 20% 2, 3
• Fosfomycin trometamol 3 g single dose is also recommended, though it may have slightly lower efficacy compared to other regimens 2, 4

Treatment Duration Considerations

• Nitrofurantoin should be prescribed for 5 days 2, 5
• TMP-SMX should be prescribed for 3 days 5, 6
• Fosfomycin is administered as a single 3 g dose 4, 5
• Clinicians should treat acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than 7 days 1

Diagnostic Approach

• In women with typical UTI symptoms (dysuria, frequency, urgency, nocturia, suprapubic pain) without vaginal discharge, a clinical diagnosis is often sufficient to initiate empiric therapy 5
• Urine culture and sensitivity testing should be obtained in patients with:
  • Recurrent UTIs 1
  • Treatment failure 5
  • History of resistant isolates 5
  • Atypical presentation 5

Special Considerations

• Local resistance patterns should guide the choice of empiric therapy 1
• Fluoroquinolones should be avoided as first-line agents due to increasing resistance rates and risk of collateral damage 1, 7
• Nitrofurantoin should not be used for upper UTIs or pyelonephritis as it doesn't achieve adequate tissue concentrations 2
• Asymptomatic bacteriuria should not be treated except in specific circumstances (pregnancy, before urologic procedures) 1

Antimicrobial Stewardship

• The three first-line agents (nitrofurantoin, TMP-SMX, fosfomycin) are effective while being less likely to produce collateral damage than second-line agents 1
• Second-line or alternate therapies should be chosen based on resistance patterns and/or allergy considerations 1
• Surveillance urine testing should be omitted in asymptomatic patients with recurrent UTIs 1

Treatment Approach for Specific Populations

• For men with UTI symptoms, longer treatment durations (7 days) are typically recommended 5
• For elderly patients (≥65 years) without relevant comorbidities, first-line antibiotics and treatment durations do not differ from those recommended for younger adults 5
• For recurrent UTIs, prophylactic strategies may be considered after acute treatment 2, 6

Common Pitfalls to Avoid

• Treating asymptomatic bacteriuria unnecessarily, which can lead to antimicrobial resistance 1
• Using fluoroquinolones as first-line empiric therapy, especially in patients with risk factors for resistant organisms 7, 8
• Using nitrofurantoin for suspected upper UTIs (pyelonephritis) due to inadequate tissue penetration 2
• Failing to obtain urine cultures in patients with risk factors for resistant organisms or treatment failure 1, 5