First-Line Treatment for Uncomplicated UTI
For uncomplicated cystitis in women, use nitrofurantoin (100 mg twice daily for 5 days), fosfomycin trometamol (3 g single dose), or trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) as first-line therapy, with the choice guided by local resistance patterns. 1, 2
Treatment Selection Algorithm
For Women with Uncomplicated Cystitis
Primary first-line options (choose based on local antibiogram):
- Fosfomycin trometamol: 3 g single dose 1, 2
- Nitrofurantoin: 100 mg twice daily for 5 days (macrocrystals or monohydrate formulations) 1, 2
- Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days—only if local E. coli resistance is <20% 1, 2
Key resistance considerations: Trimethoprim-sulfamethoxazole should be avoided if local resistance exceeds 20%, as increasing resistance rates have eliminated it as a universal first-line agent 1, 3. Nitrofurantoin demonstrates favorable resistance patterns, with only 2.6% baseline resistance and low rates of persistent resistance (5.7% at 9 months) 1.
For Men with Uncomplicated UTI
Treat for 7 days (longer duration than women): 1, 4
- Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 7 days 1
- Trimethoprim: 200 mg twice daily for 7 days 4
- Nitrofurantoin: 100 mg twice daily for 7 days 4
Always obtain urine culture before initiating treatment in men to guide antibiotic selection and rule out prostatitis 4.
Critical Antibiotic Stewardship Principles
Avoid fluoroquinolones for uncomplicated UTI: The FDA issued an advisory in 2016 warning against fluoroquinolone use for uncomplicated UTI due to disabling and serious adverse effects that create an unfavorable risk-benefit ratio 1. These agents cause significant collateral damage through alteration of fecal microbiota, selection of multidrug-resistant organisms, and increased risk of Clostridium difficile infection 1.
Avoid beta-lactams as first-line therapy: Cephalosporins and other beta-lactams promote more rapid UTI recurrence due to disruption of protective periurethral and vaginal microbiota 1.
Duration matters: Treat acute cystitis episodes for no longer than 7 days, with most women requiring only 3-5 days 1. Single-dose antibiotics show increased bacteriological persistence compared to short courses 1.
Alternative Approach for Mild-Moderate Symptoms
Symptomatic treatment with NSAIDs (e.g., ibuprofen) may be considered as an alternative to immediate antimicrobial treatment in women with mild-moderate symptoms, after discussing risks and benefits with the patient 1, 4. The risk of complications from delayed antibiotic treatment is low in this population 4.
When Urine Culture is Required
Obtain urine culture before treatment in these situations: 1, 2, 4
- Symptoms not resolving or recurring within 4 weeks after treatment 1, 2
- Atypical symptoms 1, 2
- Pregnant women 1, 2
- Recurrent UTI (≥3 UTIs/year or 2 UTIs in 6 months) 1, 2
- Men with any UTI symptoms 4
- History of resistant isolates 4
Common Pitfalls to Avoid
Do not treat asymptomatic bacteriuria: Treatment of asymptomatic bacteriuria increases the risk of symptomatic infection, promotes bacterial resistance, and increases healthcare costs, except in pregnant women or before invasive urinary procedures 1.
Do not perform routine post-treatment cultures: Urinalysis or urine cultures are not indicated for asymptomatic patients after treatment completion 1, 2.
Do not use fluoroquinolones if recent exposure: Avoid fluoroquinolones if the patient used them within the past 6 months or if local resistance exceeds 10% 1.
Avoid unnecessarily broad-spectrum antibiotics: Use the narrowest spectrum agent effective for the indication to minimize collateral damage 1.
Treatment Failure Management
If symptoms persist at treatment completion or recur within 2 weeks: 1, 2