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

Treatment of Urinary Tract Infection (UTI)

For uncomplicated UTI in women, use first-line antibiotics: nitrofurantoin (50-100 mg four times daily for 5 days), fosfomycin trometamol (3 g single dose), or trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), based on local resistance patterns. 1

Classification and Initial Assessment

The treatment approach depends critically on whether the UTI is uncomplicated or complicated:

Uncomplicated UTI

• Occurs in nonpregnant, premenopausal women with no structural/functional urinary tract abnormalities and no relevant comorbidities 1
• Can be diagnosed clinically when dysuria is present with urgency, frequency, or suprapubic pain, without vaginal discharge 1, 2
• Urine culture is NOT routinely needed for initial uncomplicated cystitis in women 1, 2

Complicated UTI

Obtain urine culture and susceptibility testing in these situations 1:

• Males (all UTIs in men are considered complicated) 1
• Pregnancy 1
• Diabetes mellitus 1
• Immunosuppression 1
• Urinary tract obstruction, foreign body, or catheterization 1
• Recent instrumentation 1
• Symptoms not resolving within 4 weeks after treatment 1
• Recurrent infections 1

First-Line Treatment Regimens

For Women with Uncomplicated Cystitis

Choose based on local antibiogram 1:

• Fosfomycin trometamol: 3 g single dose 1, 3
• Nitrofurantoin: 50-100 mg four times daily for 5 days (or 100 mg twice daily for macrocrystal formulations) 1
• Trimethoprim: 200 mg twice daily for 5 days (avoid first trimester pregnancy) 1
• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days (avoid last trimester pregnancy) 1, 3

These agents are preferred because they minimize collateral damage to normal flora and have acceptable resistance profiles 1

For Men with Uncomplicated UTI

Treat for 7 days (longer than women due to possible prostatic involvement) 1:

• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 7 days 1
• Fluoroquinolones may be used based on local susceptibility 1

For Uncomplicated Pyelonephritis

Oral fluoroquinolones remain effective when local resistance is <10% 1:

• Ciprofloxacin: 500-750 mg twice daily for 7 days 1
• Levofloxacin: 750 mg once daily for 5 days 1

Alternative oral regimens 1:

• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 14 days 1
• Cefpodoxime: 200 mg twice daily for 10 days 1
• Ceftibuten: 400 mg once daily for 10 days 1

Consider initial IV dose of ceftriaxone if using oral beta-lactams empirically 1

Complicated UTI Treatment

For patients with systemic symptoms, start with IV combination therapy 1:

• Amoxicillin PLUS aminoglycoside, OR 1
• Second-generation cephalosporin PLUS aminoglycoside, OR 1
• Third-generation cephalosporin IV 1

Treatment duration: 7-14 days (14 days for men when prostatitis cannot be excluded) 1

Only use ciprofloxacin for complicated UTI if 1:

• Local resistance rate is <10%, AND
• Patient has not used fluoroquinolones in the last 6 months, AND
• Patient is not from a urology department 1

Once hemodynamically stable and afebrile for 48 hours, consider switching to oral therapy and shortening duration to 7 days 1

Critical Management Principles

When to Obtain Urine Culture

Always obtain culture before treatment in 1:

• Recurrent UTIs (≥3 episodes in 12 months or 2 in 6 months) 1
• Suspected pyelonephritis 1
• Men with UTI symptoms 1, 2
• Pregnant women 1
• Treatment failures 1

Avoid Fluoroquinolones When Possible

Fluoroquinolones should be restricted due to increasing resistance rates and should only be used when 1:

• Local resistance is documented <10% 1
• Patient has beta-lactam anaphylaxis 1
• Other first-line agents have failed 1

Do NOT Treat Asymptomatic Bacteriuria

Asymptomatic bacteriuria should NOT be treated except in 1:

• Pregnant women 1
• Patients undergoing invasive urinary procedures 1

Do not perform surveillance urine cultures in asymptomatic patients with history of recurrent UTI 1

Recurrent UTI Prevention

Before considering antibiotic prophylaxis, implement behavioral measures 1:

• Adequate hydration to promote frequent urination 1
• Post-coital voiding 1
• Avoid spermicidal contraceptives 1

For postmenopausal women with recurrent UTI, use vaginal estrogen therapy (strong recommendation) 1

Non-antibiotic prophylaxis options 1:

• Methenamine hippurate: Strong evidence for prevention in women without urinary tract abnormalities 1
• Immunoactive prophylaxis: Reduces recurrence in all age groups 1
• Cranberry products: May reduce episodes but evidence is weak and contradictory 1
• D-mannose: Weak and contradictory evidence 1

Antibiotic prophylaxis should be reserved for when non-antimicrobial interventions fail, given risks of resistance and adverse effects 1

Common Pitfalls

• Do not routinely image patients with recurrent uncomplicated UTI unless they have risk factors for complicated infection 1
• Do not repeat urine culture after successful treatment in asymptomatic patients 1
• Avoid treating based on dipstick alone without considering clinical symptoms 1, 2
• Do not use 14-day courses for uncomplicated cystitis—treat for the shortest effective duration (3-7 days maximum) 1