What is the recommended treatment for a patient with a urinary tract infection (UTI)?

SOAP Note for Urinary Tract Infection (UTI)

Subjective

Key symptoms to document:

• Dysuria, frequency, urgency, suprapubic pain, and/or hematuria 1
• Absence of fever, flank pain, or costovertebral angle tenderness (indicates uncomplicated lower UTI vs. pyelonephritis) 1
• Duration of symptoms (short duration suggests uncomplicated UTI) 2
• Sexual activity history (recent intercourse increases risk) 1
• Previous UTI history (≥3 UTIs/year or 2 in last 6 months = recurrent UTI) 1

Complicating factors to screen for:

• Male sex, pregnancy, diabetes, immunosuppression 1
• Urinary obstruction, catheterization, recent instrumentation 1
• Recent antibiotic use (especially fluoroquinolones in last 6 months) 1
• Incomplete voiding, vesicoureteral reflux, foreign bodies 1

Objective

Physical examination:

• Abdominal examination for suprapubic tenderness 1
• Costovertebral angle tenderness (if present, suggests pyelonephritis) 1
• Pelvic examination in women to assess for vaginal atrophy, pelvic organ prolapse, or alternative diagnoses like vaginitis 1, 2

Laboratory testing:

• Urinalysis with dipstick for pyuria, hematuria, nitrites, and leukocyte esterase 1
• Urine culture with susceptibility testing is mandatory for: complicated UTIs, pyelonephritis, recurrent UTIs, men, pregnant women, and treatment failures 1
• Urine culture is NOT necessary for uncomplicated cystitis in otherwise healthy women 2, 3

Assessment

Classify the UTI type:

1. Uncomplicated cystitis (premenopausal, non-pregnant women with lower tract symptoms only, no complicating factors) 1, 3

2. Complicated UTI (presence of any complicating factor from Table 7: male sex, pregnancy, diabetes, immunosuppression, obstruction, catheter, recent instrumentation, multidrug-resistant organisms) 1

3. Uncomplicated pyelonephritis (fever >38°C, flank pain, nausea/vomiting, CVA tenderness in otherwise healthy premenopausal women) 1

4. Catheter-associated UTI (catheter in place or removed within 48 hours, with systemic symptoms) 1

Plan

For Uncomplicated Cystitis in Women:

First-line treatment options (choose one): 1

• Fosfomycin trometamol 3g single dose (one-time treatment) 1, 4
• Nitrofurantoin monohydrate/macrocrystals 100mg twice daily for 5 days 1, 3
• Pivmecillinam 400mg three times daily for 3-5 days 1

Alternative options (if local E. coli resistance <20%): 1

• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days 1, 4, 3
• Cephalosporins (e.g., cefadroxil 500mg twice daily for 3 days) 1

Avoid fluoroquinolones for uncomplicated cystitis due to collateral damage and resistance concerns 1, 3

For Uncomplicated Cystitis in Men:

Trimethoprim-sulfamethoxazole 160/800mg twice daily for 7 days 1, 4

• Fluoroquinolones may be used based on local susceptibility patterns 1
• Treatment duration is 7 days minimum (not 3 days as in women) 1

For Complicated UTI with Systemic Symptoms:

Empiric IV therapy (choose one combination): 1

• Amoxicillin plus aminoglycoside 1
• Second-generation cephalosporin plus aminoglycoside 1
• Third-generation cephalosporin IV 1

Ciprofloxacin may ONLY be used if: 1

• Local resistance rate <10% AND
• Entire treatment given orally AND
• Patient does not require hospitalization AND
• Patient has anaphylaxis to β-lactams

Do NOT use fluoroquinolones if: 1

• Patient from urology department OR
• Patient used fluoroquinolones in last 6 months

Treatment duration: 1

• 7-14 days (14 days for men when prostatitis cannot be excluded) 1
• 7 days may be sufficient if patient hemodynamically stable and afebrile for ≥48 hours 1

Mandatory: 1

• Obtain urine culture and susceptibility testing before starting antibiotics 1
• Tailor therapy based on culture results 1
• Address underlying urological abnormality 1

For Catheter-Associated UTI:

Remove or replace catheter if: 1

• Catheter has been in place ≥2 weeks at onset of CA-UTI 1

Treatment duration: 1

• 7 days for prompt symptom resolution 1
• 10-14 days for delayed response 1
• 5 days of levofloxacin 750mg daily may be considered for non-severely ill patients 1
• 3 days may be considered for women ≤65 years with CA-UTI after catheter removal, without upper tract symptoms 1

For Uncomplicated Pyelonephritis:

• Obtain urine culture and susceptibility testing 1
• Ultrasound of upper urinary tract if history of urolithiasis, renal dysfunction, or high urine pH 1
• CT scan if patient remains febrile after 72 hours or immediate deterioration 1

Key Management Principles:

Do NOT treat asymptomatic bacteriuria except in pregnant women and patients undergoing invasive urinary procedures 1

For recurrent UTIs: 1

• Diagnose each episode with urine culture 1
• Non-antimicrobial prevention first: increased fluid intake, vaginal estrogen (postmenopausal women), immunoactive prophylaxis, methenamine hippurate 1
• Antimicrobial prophylaxis only after non-antimicrobial measures fail 1

Immediate antibiotic therapy is superior to delayed treatment or ibuprofen alone 3