What is the typical prescription for a urinary tract infection (UTI)?

First-Line Treatment Options for Urinary Tract Infections (UTIs)

For uncomplicated UTIs in women, first-line treatments include nitrofurantoin, fosfomycin trometamol, or trimethoprim-sulfamethoxazole, with the choice depending on local antibiotic resistance patterns. 1

First-Line Treatment Options

For Women with Uncomplicated Cystitis:

• Fosfomycin trometamol: 3g single dose 1, 2
• Nitrofurantoin macrocrystals: 50-100mg four times daily for 5 days 1
• Nitrofurantoin monohydrate/macrocrystals: 100mg twice daily for 5 days 1
• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days (if local E. coli resistance is <20%) 1, 3
• Pivmecillinam: 400mg three times daily for 3-5 days 1

For Men with UTIs:

• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1
• Fluoroquinolones may be prescribed based on local susceptibility testing 1

Treatment Selection Considerations

Patient Factors:

• Pregnancy status: Avoid trimethoprim in first trimester and trimethoprim-sulfamethoxazole in last trimester 1
• Renal function: Adjust dosing for impaired renal function 3
• History of recurrent UTIs: Consider obtaining urine culture before initiating treatment 1

Pathogen Considerations:

• Local resistance patterns should guide empiric therapy choice 1, 4
• For multidrug-resistant organisms, consider fosfomycin, nitrofurantoin, or carbapenems based on susceptibility 1, 4

Duration of Treatment

• Uncomplicated cystitis in women: Short-course therapy (1-5 days depending on agent) 1
• UTIs in men: 7-day course typically recommended 1
• Complicated UTIs: Generally treated for 7-14 days 3

Special Situations

Recurrent UTIs:

• Diagnose via urine culture 1
• Consider non-antimicrobial preventive measures first:
  • Increased fluid intake 1
  • Vaginal estrogen in postmenopausal women 1
  • Immunoactive prophylaxis 1
  • Methenamine hippurate 1, 5
• If non-antimicrobial interventions fail, consider antimicrobial prophylaxis 1

Treatment Failure:

• Obtain urine culture and antimicrobial susceptibility testing 1
• Assume the infecting organism is not susceptible to the original agent 1
• Retreat with a 7-day regimen using a different antimicrobial agent 1

Common Pitfalls to Avoid

• Treating asymptomatic bacteriuria (except in pregnancy or before urologic procedures) 1
• Performing surveillance urine testing in asymptomatic patients with recurrent UTIs 1
• Using fluoroquinolones as first-line therapy due to increasing resistance rates and risk of adverse effects 4, 5
• Prescribing overly long courses of antibiotics, which can increase resistance without improving outcomes 1, 6

Evidence Quality Considerations

• The recommendation for nitrofurantoin is supported by randomized controlled trials showing superior efficacy compared to placebo 7
• Single-dose fosfomycin shows comparable clinical efficacy to multi-day regimens of other antibiotics, with the advantage of improved compliance 2, 5
• The optimal duration of nitrofurantoin treatment remains somewhat controversial, with UK guidelines recommending 3 days while some evidence suggests 5 days may be more appropriate 8, 6