Treatment Options for Urinary Tract Infections (UTI) and Streptococcal Infections
For uncomplicated UTIs, first-line treatments include nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, while streptococcal infections typically require penicillin-based antibiotics with treatment duration and route determined by infection severity and location. 1
Treatment of Urinary Tract Infections
First-Line Therapy for Uncomplicated UTIs
- Nitrofurantoin 50-100 mg four times daily or 100 mg twice daily for 5 days 1
- Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 3 days 1
- Fosfomycin trometamol 3 g single dose 1, 2
- Pivmecillinam 400 mg three times daily for 3-5 days (where available) 1
Second-Line Options for UTIs
- Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) 1
- Amoxicillin-clavulanate (only if local resistance patterns allow) 2, 3
- Fluoroquinolones should be avoided as first-line agents due to increasing resistance and adverse effects 1
Treatment Duration for UTIs
Special Considerations for UTIs
- Always obtain urine culture before starting antibiotics for recurrent UTIs 1
- Avoid treating asymptomatic bacteriuria except in specific populations (pregnant women, before urologic procedures) 1
- For recurrent UTIs in postmenopausal women, consider vaginal estrogen with or without lactobacillus-containing probiotics 1
- For recurrent UTIs associated with sexual activity, consider post-coital antibiotic prophylaxis 1
Treatment of Streptococcal Infections
Group A Streptococcal Pharyngitis
- Penicillin V is the treatment of choice 4
- For penicillin-allergic patients, consider macrolides or clindamycin
- Treatment duration: minimum 10 days to prevent sequelae of streptococcal disease 4
Invasive Streptococcal Infections
- Parenteral therapy with penicillin G or ampicillin
- For severe infections, combination therapy with clindamycin may be considered
- Duration depends on infection severity and clinical response
Antibiotic Resistance Considerations
- Local antibiograms should guide empiric therapy choices 1
- Fluoroquinolones should not be used as first-line therapy for uncomplicated UTIs due to increasing resistance and adverse effects 1
- E. coli resistance to ampicillin is high (approximately 75% globally), limiting its empiric use 1
- Nitrofurantoin maintains low resistance rates for UTIs, making it an excellent first-line option 1, 2
Special Populations
Pediatric Patients
- For children with UTIs, amoxicillin-clavulanate, TMP-SMX, or cephalosporins are recommended 1
- For severe infections in children, parenteral therapy with ceftriaxone, cefotaxime, or gentamicin plus ampicillin 1
Complicated UTIs
- For complicated UTIs, consider broader-spectrum agents based on local resistance patterns 1
- Options include third-generation cephalosporins with aminoglycosides 1
- For multidrug-resistant organisms, newer agents like ceftazidime-avibactam or meropenem-vaborbactam may be needed 1
Common Pitfalls to Avoid
- Treating asymptomatic bacteriuria (except in specific populations) increases resistance and recurrence rates 1
- Using fluoroquinolones for uncomplicated UTIs despite FDA warnings about disabling side effects 1
- Classifying recurrent UTIs as "complicated" leading to unnecessary use of broad-spectrum antibiotics 1
- Inadequate treatment duration for streptococcal infections (minimum 10 days needed) 4
- Not obtaining cultures before initiating therapy in recurrent or complicated infections 1
Algorithm for UTI Management
- Confirm diagnosis with appropriate symptoms and urine testing
- Determine if uncomplicated or complicated UTI
- For uncomplicated UTI:
- For complicated UTI:
- For recurrent UTIs: