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

Treatment for Uncomplicated Urinary Tract Infections

First-line treatment for uncomplicated UTIs includes nitrofurantoin, fosfomycin trometamol, or trimethoprim-sulfamethoxazole, with the specific choice guided by local resistance patterns and patient factors. 1, 2

First-line Treatment Options for Women with Uncomplicated UTIs

• Nitrofurantoin monohydrate/macrocrystals: 100 mg twice daily for 5 days - recommended for its minimal resistance and low propensity for collateral damage 1, 2, 3
• Fosfomycin trometamol: 3 g single dose - convenient single-dose regimen, though slightly lower efficacy than other first-line agents 1, 2
• Pivmecillinam: 400 mg three times daily for 3-5 days - avoid if early pyelonephritis is suspected 1
• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days - only if local resistance rates are <20% or if the patient hasn't used it for UTI in the previous 3 months 1, 2, 4

Alternative Options

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

Treatment for Men with Uncomplicated UTIs

• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 7 days 1, 5
• Men require longer treatment duration (7 days) compared to women 5

Clinical Decision-Making Algorithm

1. Confirm diagnosis:

   • Presence of typical symptoms (dysuria, frequency, urgency, suprapubic pain) without vaginal discharge is usually sufficient for diagnosis in women 5
   • Reserve urine culture for:
     • Suspected pyelonephritis
     • Symptoms that don't resolve or recur within 4 weeks after treatment
     • Atypical symptoms
     • Pregnant women 1

2. Select appropriate antibiotic:

   • Consider local resistance patterns
   • Check patient's allergy history
   • Review patient's recent antibiotic use (avoid same class if used in past 3 months)
   • Consider renal function (especially for nitrofurantoin) 2, 5

3. Consider symptomatic therapy:

   • For women with mild to moderate symptoms, symptomatic therapy (e.g., ibuprofen) may be considered as an alternative to antimicrobial treatment in consultation with individual patients 1

Follow-up Recommendations

• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1
• For women whose symptoms don't resolve by the end of treatment or recur within 2 weeks:
  • Perform urine culture and antimicrobial susceptibility testing
  • Assume the infecting organism is not susceptible to the original agent
  • Retreat with a 7-day regimen using another agent 1

Important Considerations and Pitfalls

• Avoid fluoroquinolones for uncomplicated UTIs due to increasing resistance rates and risk of adverse effects 2, 6
• Do not treat asymptomatic bacteriuria except in pregnant women or before urologic procedures 2
• Consider local resistance patterns when selecting empiric therapy, particularly for trimethoprim-sulfamethoxazole 1, 2, 7
• Nitrofurantoin should be avoided in patients with suspected pyelonephritis or significant renal impairment (CrCl <30 mL/min) as it may not achieve adequate concentrations in the upper urinary tract 3, 8
• Recurrent UTIs (≥3 UTIs/year or ≥2 UTIs in 6 months) may require different management strategies, including prophylaxis 1, 2