What is the recommended treatment for uncomplicated urinary tract infections (UTIs)?

Treatment of Uncomplicated Urinary Tract Infections

For women with uncomplicated UTI, first-line treatment should be 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

First-Line Antimicrobial Options for Women

The 2024 European Association of Urology guidelines provide the most current treatment framework 1:

• Fosfomycin trometamol: 3 g single dose 1, 2

  • Minimal resistance and collateral damage
  • FDA-approved specifically for uncomplicated cystitis in women 2
  • May have slightly lower efficacy than other agents but excellent for antimicrobial stewardship 1

• Nitrofurantoin: 100 mg twice daily for 5 days 1

  • Available as monohydrate, macrocrystals, or prolonged-release formulations
  • Alternative dosing: 50-100 mg four times daily for 5 days 1
  • Avoid if early pyelonephritis suspected 1

• Pivmecillinam: 400 mg three times daily for 3-5 days 1

  • Limited availability (primarily Europe, not in North America) 1
  • Minimal resistance but may have inferior efficacy compared to other options 1

Alternative Antimicrobial Options

When first-line agents cannot be used 1:

• Trimethoprim-sulfamethoxazole: 160/800 mg (one double-strength tablet) twice daily for 3 days 1, 3

  • Only use if local E. coli resistance is <20% 1
  • Avoid if used for UTI in previous 3 months 1
  • Contraindicated in last trimester of pregnancy 1

• Trimethoprim alone: 200 mg twice daily for 5 days 1

  • Not in first trimester of pregnancy 1

• Cephalosporins (e.g., cefadroxil): 500 mg twice daily for 3 days 1

  • Only if local E. coli resistance <20% 1

• Fluoroquinolones: Reserve for more serious infections 1

  • Highly efficacious but cause significant collateral damage (antimicrobial resistance) 1
  • Should NOT be used as first-line for simple cystitis 1

Treatment for Men

Men require longer treatment duration 1:

• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 7 days 1, 4
• Fluoroquinolones can be prescribed according to local susceptibility testing 1
• Nitrofurantoin: 7-day course 4
• Always obtain urine culture before treatment 4

Non-Antimicrobial Management

For women with mild to moderate symptoms, symptomatic treatment with ibuprofen may be considered as an alternative to antibiotics 1:

• Discuss risks and benefits with patient 1
• Risk of complications is low 4
• Delayed antibiotic approach is reasonable 4

Critical Diagnostic Considerations

Urine culture is NOT routinely needed for typical uncomplicated cystitis 1. However, obtain culture in these situations 1:

• Suspected acute pyelonephritis
• Symptoms not resolving or recurring within 4 weeks after treatment
• Atypical symptoms
• Pregnant women
• Men with UTI symptoms 4
• Treatment failure 1

Management of Treatment Failure

If symptoms persist or recur within 2 weeks 1:

• Obtain urine culture and susceptibility testing 1
• Assume organism is resistant to initial agent 1
• Retreat with 7-day regimen using different antimicrobial class 1

Important Caveats

Avoid these agents for empiric treatment 1:

• Amoxicillin or ampicillin alone: Very high resistance rates worldwide 1
• Beta-lactams generally: Inferior efficacy and more adverse effects compared to other UTI antimicrobials 1
  • Exception: Pivmecillinam is acceptable 1
  • Use amoxicillin-clavulanate, cefdinir, cefaclor, or cefpodoxime-proxetil only when other agents cannot be used 1

Post-treatment monitoring 1:

• Do NOT perform routine urinalysis or cultures in asymptomatic patients after treatment 1

Special populations requiring different approach 4:

• Adults ≥65 years: Obtain urine culture with susceptibility testing to adjust antibiotics after initial empiric treatment 4
• Consider urethritis and prostatitis in men with UTI symptoms 4