What are the recommended treatments for urinary tract infections (UTIs)?

Recommended Treatments for Urinary Tract Infections (UTIs)

First-line treatment for uncomplicated UTIs in women should include nitrofurantoin 100 mg twice daily for 5 days, fosfomycin trometamol 3 g single dose, or pivmecillinam 400 mg three times daily for 3-5 days. 1, 2

Treatment Algorithm for Uncomplicated UTIs

First-Line Treatment Options for Women

• Nitrofurantoin macrocrystals 100 mg twice daily for 5 days 1, 2, 3
• Fosfomycin trometamol 3 g single dose (recommended only for uncomplicated cystitis) 1, 2
• Pivmecillinam 400 mg three times daily for 3-5 days 1, 3

Alternative Options When First-Line Agents Cannot Be Used

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (only if local resistance rates are <20%) 1, 2, 4
• Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) if local E. coli resistance is <20% 1
• Trimethoprim 200 mg twice daily for 5 days (avoid in first trimester of pregnancy) 1

Treatment for Men

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days 1, 5
• Fluoroquinolones can be prescribed according to local susceptibility testing 1

Management of Treatment Failure

• For women whose symptoms don't resolve by the end of treatment or recur within 2 weeks, obtain a urine culture with antimicrobial susceptibility testing 1
• Assume the infecting organism is not susceptible to the original agent and retreat with a 7-day regimen using a different antibiotic 1
• Avoid retreating with the same antibiotic class 1

Management of Recurrent UTIs

Recurrent UTIs (rUTIs) are defined as ≥3 UTIs per year or ≥2 UTIs in 6 months 1

Diagnostic Approach

• Confirm diagnosis via urine culture 1
• Extensive workup (cystoscopy, ultrasound) is not routinely recommended for women <40 years without risk factors 1

Prevention Strategies (in order of preference)

1. Non-antimicrobial measures:

   • Increased fluid intake for premenopausal women 1
   • Vaginal estrogen replacement for postmenopausal women 1
   • Immunoactive prophylaxis 1
   • Methenamine hippurate for women without urinary tract abnormalities 1
   • Probiotics with proven efficacy for vaginal flora regeneration 1

2. Antimicrobial prophylaxis (when non-antimicrobial interventions fail):

   • Continuous or post-coital antimicrobial prophylaxis 1
   • Self-administered short-term antimicrobial therapy for patients with good compliance 1
   • For post-coital infections: low-dose antibiotic within 2 hours of sexual activity for 6-12 months 1

Special Considerations

Postmenopausal Women

• Vaginal estrogen replacement is strongly recommended to prevent recurrent UTIs 1
• Consider combination with lactobacillus-containing probiotics 1

Pregnancy

• Avoid trimethoprim in first trimester and trimethoprim-sulfamethoxazole in last trimester 1
• For pyelonephritis in pregnancy, hospitalization and IV antibiotics are indicated 3

Important Caveats

• Avoid fluoroquinolones as first-line therapy despite their efficacy, due to risk of "collateral damage" and increasing resistance 2, 5
• Avoid treating asymptomatic bacteriuria in women with rUTIs, as this fosters antimicrobial resistance and increases recurrence 1, 2
• Do not use amoxicillin or ampicillin for empirical treatment due to poor efficacy and high resistance rates 2
• Consider local resistance patterns when selecting empiric therapy, as resistance varies considerably between regions 2, 5
• Nitrofurantoin should not be used for upper UTIs or pyelonephritis as it doesn't achieve adequate tissue concentrations 2