Treatment of Urinary Tract Infections (UTIs)
For uncomplicated and complicated UTIs, first-line treatments should be selected based on local resistance patterns, with fosfomycin, nitrofurantoin, and pivmecillinam recommended as first-line agents for uncomplicated cystitis in women due to their minimal resistance profiles and effectiveness.
Uncomplicated Cystitis in Women
First-line Treatment Options
- Fosfomycin trometamol: 3g single dose 1, 2
- Nitrofurantoin: 100mg twice daily for 5 days (macrocrystals) or 50-100mg four times daily for 5 days 1, 3
- Pivmecillinam: 400mg three times daily for 3-5 days 1, 3
Alternative Treatment Options (when first-line agents cannot be used)
- Cephalosporins (e.g., cefadroxil): 500mg twice daily for 3 days (if local E. coli resistance <20%) 1, 3
- Trimethoprim: 200mg twice daily for 5 days (avoid in first trimester of pregnancy) 1, 3
- Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days (avoid in last trimester of pregnancy) 1, 4
- Fluoroquinolones: Should be reserved for important uses other than acute cystitis due to potential for collateral damage 1, 5
UTIs in Men
- Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1, 3
- Fluoroquinolones: Can be prescribed according to local susceptibility testing 1, 3, 6
- Nitrofurantoin: 100mg twice daily for 7 days 6
Acute Pyelonephritis
Outpatient Treatment
- Oral ciprofloxacin: 500mg twice daily for 7 days (if local resistance <10%) 1
- Oral levofloxacin: 750mg once daily for 5 days (if local resistance <10%) 1
- Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 14 days (if pathogen is known to be susceptible) 1
Initial Parenteral Therapy (when needed)
- One-time dose of ceftriaxone 1g IV or a 24-hour dose of an aminoglycoside before starting oral therapy 1
- This approach is especially recommended when fluoroquinolone resistance exceeds 10% 1
Hospitalized Patients
- Initial IV antimicrobial regimen options 1:
- Fluoroquinolone
- Aminoglycoside (with or without ampicillin)
- Extended-spectrum cephalosporin or extended-spectrum penicillin (with or without aminoglycoside)
- Carbapenem
Special Considerations
Diagnostic Approach
- Uncomplicated cystitis can be diagnosed based on symptoms (dysuria, frequency, urgency) without urine culture 1, 6
- Urine culture is recommended for 1, 3:
Antimicrobial Resistance Considerations
- Local resistance patterns should guide empiric therapy selection 1
- Avoid empiric use of agents with local resistance rates >20% 1, 7
- E. coli is the most common pathogen (75-95% of cases) 1
- Nitrofurantoin, fosfomycin, and pivmecillinam maintain good activity against most uropathogens globally 1, 5
Recurrent UTIs
- Diagnose recurrent UTI via urine culture 1
- Consider prophylactic antimicrobials when non-antimicrobial interventions fail 3
- For women with symptoms that don't resolve by end of treatment or recur within 2 weeks, perform urine culture and susceptibility testing 1
- Resistance rates may be higher in recurrent UTIs, particularly for trimethoprim (21.4%) and cotrimoxazole (19.3%) 7
Treatment Duration
- Uncomplicated cystitis: 1-5 days depending on the agent 8, 6
- Pyelonephritis with β-lactam agents: 10-14 days 1
- UTIs in men: 7 days 1, 3, 6
Complicated UTIs and Resistant Organisms
- For UTIs caused by ESBL-producing E. coli: nitrofurantoin, fosfomycin, pivmecillinam may be effective 5
- For carbapenem-resistant Enterobacteriaceae: ceftazidime-avibactam, meropenem/vaborbactam, aminoglycosides including plazomicin, or cefiderocol 5
Pitfalls to Avoid
- Amoxicillin or ampicillin should not be used for empirical treatment due to poor efficacy and high resistance rates 1, 3
- β-lactams (except pivmecillinam) generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials 1, 3
- Fluoroquinolones should be reserved for more serious infections due to increasing resistance and risk of adverse effects 1, 3, 5
- Avoid routine post-treatment urinalysis or urine cultures in asymptomatic patients 1