Management of Urinary Tract Infections
The management of urinary tract infections (UTIs) should be based on proper diagnosis, appropriate antimicrobial selection guided by local resistance patterns, and treatment duration of 7-14 days for most UTIs, with shorter courses for uncomplicated cystitis in women. 1
Diagnosis
- UTI diagnosis requires both clinical symptoms and laboratory confirmation with a properly collected urine specimen 1
- Significant bacteriuria is defined as ≥50,000 CFUs/mL of a single urinary pathogen in children and typically ≥100,000 CFUs/mL in adults 1
- Avoid testing and treating asymptomatic bacteriuria except in pregnancy, as this contributes to antimicrobial resistance 1
- Symptoms of cystitis include dysuria, frequency, urgency, and suprapubic pain; pyelonephritis presents with fever, flank pain, and costovertebral angle tenderness 2, 3
Treatment Approach for Uncomplicated UTIs
Uncomplicated Cystitis in Women
- First-line options (for 3-5 days): 1, 2
- Nitrofurantoin 100mg BID for 5 days
- Trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days (if local resistance <20%)
- Fosfomycin single dose
- Pivmecillinam for 5 days
Uncomplicated Pyelonephritis
- Oral therapy for mild-moderate cases: 1, 2
- Fluoroquinolones (if local resistance permits)
- TMP-SMX (if susceptibility confirmed)
- Parenteral therapy for severe cases: 1
- Third-generation cephalosporins
- Gentamicin or tobramycin
- Piperacillin
- Treatment duration: 7-14 days 1
Treatment Approach for Complicated UTIs
- Complicated UTIs involve anatomical/functional abnormalities, immunosuppression, pregnancy, or multidrug-resistant organisms 1, 4
- Obtain urine culture before starting antibiotics 1
- Initial empiric therapy should be broad-spectrum based on local resistance patterns 4, 1
- Consider carbapenems or piperacillin-tazobactam for serious complicated UTIs with risk factors for resistant organisms 4
- Adjust therapy based on culture results and clinical response 1
- Treatment duration typically 7-14 days, may extend to 21 days in severe cases 1
Special Populations
Pediatric Patients
- Base route of administration on practical considerations and patient's ability to retain oral medications 1
- Parenteral options for children unable to take oral medications: 1
- Ceftriaxone: 75 mg/kg every 24h
- Cefotaxime: 150 mg/kg/day divided every 6-8h
- Gentamicin: 7.5 mg/kg/day divided every 8h
- Oral options for children: 1
- Amoxicillin-clavulanate: 20-40 mg/kg/day in 3 doses
- Cephalosporins (various options)
- TMP-SMX: 6-12 mg/kg trimethoprim component per day in 2 doses
Elderly Patients
- Consider atypical presentations and avoid treating asymptomatic bacteriuria 1
- Avoid fluoroquinolones due to risk of adverse effects in elderly with comorbidities 1
- Consider drug interactions and renal function when selecting antimicrobials 1, 3
Prevention of Recurrent UTIs
- For postmenopausal women: vaginal estrogen with or without lactobacillus-containing probiotics 1
- For premenopausal women with post-coital infections: low-dose antibiotics within 2 hours of sexual activity for 6-12 months 1
- For premenopausal women with non-sexually related recurrent UTIs: low-dose daily antibiotic prophylaxis 1
- Non-antibiotic alternatives: methenamine hippurate and/or lactobacillus-containing probiotics 1
- Antibiotic prophylaxis options: 1
- Nitrofurantoin 50 mg
- TMP-SMX 40/200 mg
- Trimethoprim 100 mg
- Consider rotating antibiotics every 3 months to reduce resistance development
Common Pitfalls to Avoid
- Treating asymptomatic bacteriuria (except in pregnancy) 1
- Using broad-spectrum antibiotics for uncomplicated UTIs 1, 4
- Prolonged antibiotic courses for uncomplicated cystitis 1, 2
- Failing to adjust empiric therapy based on culture results 1
- Using fluoroquinolones as first-line empiric therapy due to increasing resistance 4, 3
- Not considering local resistance patterns when selecting empiric therapy 1, 5
By following these evidence-based recommendations, clinicians can effectively manage UTIs while practicing good antimicrobial stewardship to minimize resistance development.