What are the current guidelines for treating urinary tract infections (UTIs)?

Latest UTI Guidelines (2024-2025)

According to the most recent 2024 European Association of Urology guidelines, UTI treatment should be tailored based on classification (uncomplicated vs. complicated), with specific antibiotic recommendations and treatment durations for each category. 1

Classification of UTIs

• UTIs are classified as uncomplicated or complicated, with male UTIs generally considered complicated 2
• Complicated UTIs are associated with factors such as obstruction, foreign bodies, incomplete voiding, vesicoureteral reflux, recent instrumentation, pregnancy, diabetes, immunosuppression, and healthcare-associated infections 1
• The microbial spectrum in complicated UTIs is broader than uncomplicated UTIs, with higher likelihood of antimicrobial resistance 1, 2

Diagnostic Approach

• Obtain urine culture and susceptibility testing before initiating antimicrobial therapy for complicated UTIs 1, 2
• Evaluate for underlying urological abnormalities or complicating factors that may require management 2
• For uncomplicated UTIs in otherwise healthy patients, empiric therapy may be initiated without culture 3

Treatment Recommendations for Uncomplicated UTIs

• First-line empiric therapy for acute uncomplicated cystitis in healthy non-pregnant females:

  • Nitrofurantoin (5-day course) 3, 4
  • Fosfomycin trometamol (3g single dose) 3, 4
  • Pivmecillinam (5-day course, not available in some countries) 3, 4

• Second-line options include:

  • Oral cephalosporins (e.g., cephalexin, cefixime) 3
  • Amoxicillin-clavulanate 3, 5
  • Fluoroquinolones (only when local resistance rates are <10% and patient has not used fluoroquinolones in the past 6 months) 1, 3

Treatment Recommendations for Complicated UTIs

• Strong recommendation for empirical treatment with one of the following combinations 1:

  • Amoxicillin plus an aminoglycoside
  • A second-generation cephalosporin plus an aminoglycoside
  • An intravenous third-generation cephalosporin

• Ciprofloxacin should only be used when 1, 2:

  • Local resistance rate is <10%
  • Entire treatment can be given orally
  • Patient does not require hospitalization
  • Patient has anaphylaxis to β-lactam antimicrobials

• Avoid fluoroquinolones for empirical treatment if 1, 2, 6:

  • Patient is from a urology department
  • Patient has used fluoroquinolones in the last 6 months

Treatment Duration

• Uncomplicated cystitis: 3-5 days of treatment 4
• Complicated UTIs: 7-14 days 1
• Male UTIs: 14 days when prostatitis cannot be excluded 2
• Consider shorter treatment duration (7 days) for complicated UTIs when the patient is hemodynamically stable and has been afebrile for at least 48 hours 1, 2

Special Considerations for Antimicrobial Resistance

• For ESBL-producing E. coli, treatment options include nitrofurantoin, fosfomycin, and pivmecillinam for lower UTIs 3, 5
• For more severe infections with resistant organisms, options include carbapenems, ceftazidime-avibactam, ceftolozane-tazobactam, and aminoglycosides 3, 5
• Trimethoprim-sulfamethoxazole should only be used when local resistance rates are below 20% 7
• FDA-approved indications for trimethoprim-sulfamethoxazole include UTIs caused by E. coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris 8

Safety Netting and Follow-up

• Patients should seek immediate medical attention if 6:

  • Symptoms do not resolve within 4 weeks after treatment completion
  • Symptoms recur within 2 weeks
  • Signs of pyelonephritis develop (fever, chills, flank pain, nausea, vomiting)

• For patients whose symptoms do not resolve by the end of treatment or recur within 2 weeks, perform urine culture with antimicrobial susceptibility testing 6

• Routine post-treatment urinalysis or urine cultures are NOT indicated for asymptomatic patients 6

Management of Recurrent UTIs

• Diagnose recurrent UTI via urine culture 6
• Consider preventive measures including non-antimicrobial approaches and antimicrobial prophylaxis in selected cases 6
• For patients with good compliance, self-administered short-term antimicrobial therapy may be considered 6

Common Pitfalls to Avoid

• Do not perform extensive routine workup in women younger than 40 years with recurrent UTI and no risk factors 6
• Avoid using fluoroquinolones empirically when resistance rates are high or when patients have recently used these agents 1, 6
• Do not treat asymptomatic bacteriuria except in pregnancy or prior to urologic procedures 1
• Recognize that persistent symptoms despite appropriate treatment may indicate underlying structural or functional abnormalities requiring further investigation 6