Treatment of Urinary Tract Infections
First-line treatment for uncomplicated UTIs is nitrofurantoin (100 mg twice daily for 5 days), trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), or fosfomycin (3 g single dose), depending on local resistance patterns. 1
Diagnosis
- Obtain urinalysis and urine culture with sensitivity testing before initiating treatment to confirm diagnosis and guide therapy 2, 1
- Typical symptoms include dysuria, frequency, urgency, and possibly hematuria or new/worsening incontinence 1
- Diagnosis can be made with high probability based on focused history of lower urinary tract symptoms and absence of vaginal discharge 1
Treatment of Uncomplicated UTIs
First-Line Options
- Nitrofurantoin: 100 mg twice daily for 5 days (clinical efficacy ~93%) 1
- Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days (clinical efficacy ~93%), if local resistance is <20% 1, 3, 4
- Fosfomycin: 3 g single dose (clinical efficacy ~91%) 1, 4
Treatment Duration
- Treat uncomplicated UTIs with as short a duration of antibiotics as reasonable, generally no longer than 7 days 2, 4
- For most uncomplicated cases, 3-5 days of therapy is sufficient 4, 5
Special Considerations
- Avoid fluoroquinolones for uncomplicated UTIs due to concerns about resistance and adverse effects 2, 1, 6
- In July 2016, the FDA issued an advisory warning against using fluoroquinolones for uncomplicated UTIs due to unfavorable risk-benefit ratio 2
- For patients with resistant organisms, culture-directed parenteral antibiotics may be needed for as short a course as reasonable 2
Management of Complicated UTIs
- Complicated UTIs occur in patients with structural or functional abnormalities of the urinary tract, immune suppression, or pregnancy 2
- For complicated UTIs, consider the following treatment options 2:
- Amoxicillin plus an aminoglycoside
- A second-generation cephalosporin plus an aminoglycoside
- An intravenous third-generation cephalosporin
Management of Recurrent UTIs
- Defined as ≥3 UTIs in 1 year or ≥2 in 6 months 1
- Obtain urine culture with each symptomatic episode prior to initiating treatment 2
- Consider patient-initiated treatment (self-start) for select reliable patients 2, 1
Prevention Strategies for Recurrent UTIs
- For postmenopausal women: Vaginal estrogen therapy with or without lactobacillus-containing probiotics 2, 1
- For premenopausal women with post-coital infections: Low-dose antibiotic within 2 hours of sexual activity 2
- For infections unrelated to sexual activity: Consider low-dose daily antibiotic prophylaxis 2
- Non-antibiotic alternatives: Methenamine hippurate, lactobacillus-containing probiotics, increased fluid intake, and cranberry products 2, 5
Common Pitfalls and Caveats
- Avoid treating asymptomatic bacteriuria, which is common in older adults and does not require treatment 2
- Avoid classifying patients with recurrent UTIs as "complicated" as this often leads to use of broad-spectrum antibiotics with long durations of treatment 2
- If symptoms persist despite treatment, repeat urine culture to assess for ongoing bacteriuria before prescribing additional antibiotics 2
- Antibiotic resistance among uropathogens is increasing; adhere to antimicrobial stewardship principles 2, 6
- Use nitrofurantoin when possible as a first-line agent for re-treatment since resistance is low and, if present, decays quickly 2