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

Treatment for Uncomplicated and Complicated UTIs

For uncomplicated UTIs, first-line treatment should be nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, with treatment duration of 3-5 days depending on the agent selected. 1, 2

Uncomplicated UTIs

First-Line Treatment Options

• Nitrofurantoin monohydrate/macrocrystals: 100 mg twice daily for 5 days - offers minimal resistance and low propensity for collateral damage 1, 2
• Fosfomycin trometamol: 3 g single dose - convenient single-dose regimen specifically indicated for uncomplicated UTIs in women 3, 2
• TMP-SMX: 160/800 mg twice daily for 3 days - only if local resistance rates are <20% or if the infecting strain is known to be susceptible 1, 2
• Pivmecillinam: 400 mg three times daily for 3-5 days - alternative option with good efficacy 2

Alternative Options (When First-Line Agents Cannot Be Used)

• Cephalosporins (e.g., cefadroxil): 500 mg twice daily for 3 days - only if local E. coli resistance is <20% 2
• Fluoroquinolones should be avoided as first-line therapy due to concerns about collateral damage and increasing resistance 1, 2

Diagnostic Approach

• Obtain urinalysis for symptomatic patients 2
• Urine culture is recommended before initiating treatment for:
  • Suspected pyelonephritis
  • Symptoms that don't resolve within 4 weeks after treatment
  • Women with atypical symptoms
  • Pregnant women 2, 1

Complicated UTIs

Definition and Approach

• Complicated UTIs include infections in patients with functional or structural abnormalities, immunocompromised states, or upper tract involvement 1
• Always obtain urine culture and susceptibility testing before initiating antibiotics 1

Treatment

• Initial empiric therapy should be based on severity, risk factors, and local resistance patterns 1
• Culture-directed therapy should be adjusted based on susceptibility results 1
• For acute cystitis episodes associated with resistant organisms, culture-directed parenteral antibiotics may be used for as short a course as reasonable, generally no longer than seven days 2
• Treatment duration is typically 7 days, though this may vary based on the specific clinical scenario 2

Recurrent UTIs (rUTIs)

Definition and Diagnosis

• Defined as ≥3 UTIs per year or ≥2 UTIs in 6 months 1, 2
• Diagnose via urine culture 2

Management Approaches

• Obtain urinalysis, urine culture and sensitivity with each symptomatic episode prior to initiating treatment 2
• Patient-initiated treatment (self-start) may be offered to select patients while awaiting urine cultures 2
• Preventive strategies:
  • Increased fluid intake for premenopausal women 2
  • Vaginal estrogen replacement in postmenopausal women 2
  • Immunoactive prophylaxis 2
  • Consider probiotics or cranberry products, though evidence is limited 2

Important Considerations

Asymptomatic Bacteriuria

• Do not screen for or treat asymptomatic bacteriuria except in pregnant women or before invasive urologic procedures 2, 1
• Surveillance urine testing should be omitted in asymptomatic patients with rUTIs 2

Treatment Failure

• If symptoms persist or recur within 2-4 weeks after treatment completion, obtain urine culture and susceptibility testing 2, 4
• Assume the infecting organism is not susceptible to the original agent 2
• Retreatment with a 7-day regimen using another agent should be considered 2

Antimicrobial Stewardship

• Use antibiotics for as short a duration as reasonable to minimize resistance 2, 5
• Consider local resistance patterns when selecting empiric therapy 1, 4
• For uncomplicated UTIs, symptomatic therapy (e.g., ibuprofen) may be considered as an alternative to antimicrobial treatment in consultation with individual patients 2, 5