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

Treatment for Urinary Tract Infections (UTIs)

First-line treatment for uncomplicated UTIs should include nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, depending on local antibiogram patterns, for a duration of 5-7 days. 1, 2

Diagnosis and Initial Assessment

• Obtain urine culture before initiating antimicrobial therapy to confirm diagnosis and guide treatment based on susceptibility patterns 1
• Significant bacteriuria in infants and children is defined as at least 50,000 CFUs per mL of a single urinary pathogen 1
• Patient-initiated treatment (self-start) may be offered to select patients with recurrent UTIs while awaiting urine culture results 1

First-Line Treatment Options for Uncomplicated UTIs

• Nitrofurantoin: Recommended as first-line therapy due to low resistance rates and minimal collateral damage 1, 2
• Trimethoprim-sulfamethoxazole (TMP-SMX): Use only if local resistance rates are low 1, 3
• Fosfomycin trometamol: Single 3g dose option for uncomplicated cystitis 2, 4
• Pivmecillinam: 5-day course (available in some countries) 2, 3

Treatment Duration

• Uncomplicated cystitis: 5-7 days (generally no longer than 7 days) 1, 2
• Complicated UTIs: 7-14 days, depending on clinical response 1
• Pyelonephritis: 7-14 days 1
• Single-dose treatments (except fosfomycin) are associated with increased risk of bacteriological persistence compared to longer courses 1

Special Populations

Children with UTIs

• Oral treatment options include cephalosporins, amoxicillin-clavulanate, or TMP-SMX 1
• Parenteral therapy should be considered for toxic-appearing children or those unable to retain oral medications 1
• Duration of therapy should be 7-14 days 1
• Nitrofurantoin should not be used for febrile UTIs in infants as it doesn't achieve adequate serum concentrations to treat pyelonephritis 1

Complicated UTIs

• For patients with systemic symptoms, recommended empiric treatments include: 1
  • Amoxicillin plus an aminoglycoside
  • Second-generation cephalosporin plus an aminoglycoside
  • Intravenous third-generation cephalosporin
• For culture-resistant organisms, parenteral antibiotics may be required for as short a course as reasonable (generally ≤7 days) 1

Recurrent UTIs

• Obtain urine culture with each symptomatic episode prior to treatment 1
• Consider prophylactic antibiotics for prevention after discussing risks and benefits 1
• For postmenopausal women with recurrent UTIs, consider vaginal estrogen with or without lactobacillus-containing probiotics 1
• For premenopausal women with post-coital infections, consider low-dose antibiotics within 2 hours of sexual activity 1

Important Considerations

• Avoid fluoroquinolones as first-line therapy due to potential for serious adverse effects and increasing resistance 1
• Do not treat asymptomatic bacteriuria except in pregnant women, before urologic procedures, or in specific high-risk populations 1
• Avoid surveillance urine testing in asymptomatic patients with history of recurrent UTIs 1
• Base antibiotic selection on local resistance patterns and adjust according to culture results 1, 2
• Consider antibiotic stewardship to minimize resistance development 1, 2

Common Pitfalls to Avoid

• Using broad-spectrum antibiotics unnecessarily, which promotes antimicrobial resistance 2, 3
• Treating for longer than necessary, which increases risk of adverse effects and resistance 1, 3
• Using fluoroquinolones for uncomplicated UTIs despite FDA warnings about unfavorable risk-benefit ratio 1
• Treating asymptomatic bacteriuria, which increases resistance and may lead to more symptomatic episodes 1
• Failing to adjust empiric therapy based on culture results 1

Remember that the goal of treatment is to eliminate infection, prevent complications, and reduce the likelihood of renal damage while minimizing the development of antimicrobial resistance 1, 2.