What is the recommended treatment for urinary tract infections (UTIs)?

Treatment of Urinary Tract Infections (UTIs)

For urinary tract infections, first-line empirical treatment should include nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, with the choice dependent on local antibiogram patterns and patient factors. 1, 2

Classification of UTIs

UTIs are classified into:

• Uncomplicated UTIs: Infections in patients with normal urinary tract anatomy and function

  • Typically seen in otherwise healthy women 1
  • Common pathogens: E. coli, Klebsiella, Proteus 1

• Complicated UTIs: Infections associated with factors that increase risk of treatment failure

  • Risk factors include: obstruction, foreign body, incomplete voiding, vesicoureteral reflux, recent instrumentation, diabetes, immunosuppression, pregnancy, healthcare-associated infections 1
  • Broader microbial spectrum including E. coli, Proteus, Klebsiella, Pseudomonas, Serratia, and Enterococcus 1

Diagnostic Approach

• Obtain urine culture before initiating treatment for suspected UTI 1
• Consider local resistance patterns when selecting empiric therapy 1
• For recurrent UTIs, always obtain pretreatment urine culture when an acute episode is suspected 1

Treatment Recommendations

Uncomplicated UTIs

• First-line options (based on local susceptibility patterns):

  • Nitrofurantoin 1, 2
  • Trimethoprim-sulfamethoxazole (if local resistance <20%) 1, 3
  • Fosfomycin (single 3g dose) 2

• Second-line options:

  • Oral cephalosporins (cephalexin, cefixime) 1, 2
  • Amoxicillin-clavulanate 1, 2
  • Fluoroquinolones (only when first-line agents cannot be used due to resistance or allergies) 1, 2

• Duration of therapy: 3-5 days for uncomplicated cystitis in women 2, 4

Complicated UTIs

• Recommended empirical treatment (for patients with systemic symptoms):

  • Amoxicillin plus an aminoglycoside 1
  • Second-generation cephalosporin plus an aminoglycoside 1
  • Intravenous third-generation cephalosporin 1

• Oral therapy options (when appropriate):

  • Ciprofloxacin (only if local resistance <10% and patient hasn't used fluoroquinolones in the past 6 months) 1

• Duration of therapy: 7-14 days (14 days for men when prostatitis cannot be excluded) 1

Special Populations

Children with UTIs

• Parenteral options: Ceftriaxone, cefotaxime, gentamicin 1
• Oral options: Amoxicillin-clavulanate, cephalosporins, TMP-SMX 1
• Duration: 7-14 days 1
• Important note: Avoid nitrofurantoin for febrile UTIs in infants as it doesn't achieve adequate serum concentrations 1

Women with Recurrent UTIs

• Obtain urine culture with each symptomatic episode 1
• Consider patient-initiated (self-start) treatment for reliable patients 1
• Prevention strategies:
  • Postmenopausal women: Vaginal estrogen with/without lactobacillus probiotics 1
  • Premenopausal women with post-coital infections: Low-dose antibiotics within 2 hours of sexual activity 1
  • Non-antibiotic alternatives: Methenamine hippurate, lactobacillus probiotics 1

Important Clinical Considerations

• Avoid fluoroquinolones for empirical treatment if:

  • Local resistance rates are ≥10% 1
  • Patient has used fluoroquinolones in the last 6 months 1
  • Patient is from a urology department (higher resistance rates) 1

• Avoid treating asymptomatic bacteriuria except in:

  • Pregnant women 1, 5
  • Before invasive urological procedures 1, 5
  • Kidney transplant recipients 5

• For catheter-associated UTIs:

  • Treat according to complicated UTI guidelines 1
  • Catheterization duration is the most important risk factor 1

• Antibiotic resistance considerations:

  • Use nitrofurantoin when possible for retreatment of recurrent UTIs as resistance is low 1
  • Consider local antibiograms when selecting empiric therapy 1
  • Adjust therapy based on culture results 1

Treatment Failure

• If symptoms persist despite treatment, repeat urine culture before prescribing additional antibiotics 1
• For patients with UTIs resistant to oral antibiotics, consider culture-directed parenteral antibiotics for as short a course as reasonable (generally ≤7 days) 1

Remember that appropriate management of any underlying urological abnormality or complicating factor is mandatory for successful treatment of complicated UTIs 1.