Treatment for Uncomplicated Urinary Tract Infection (UTI)
Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is the preferred first-line treatment for uncomplicated UTI in women, offering minimal resistance and low collateral damage. 1, 2
First-Line Treatment Options for Women
The choice among first-line agents should be guided by local resistance patterns, recent antibiotic exposure, and patient-specific factors:
Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is recommended as the optimal first-line agent due to minimal resistance rates and low propensity for selecting multidrug-resistant organisms 1, 2, 3
Fosfomycin trometamol 3 g as a single dose offers convenient single-dose administration, though efficacy is slightly lower than nitrofurantoin 1, 2, 3
Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days should only be used if local E. coli resistance rates are <20% OR if the patient has not used it for UTI in the previous 3 months 1, 2, 4
Pivmecillinam 400 mg three times daily for 3-5 days is an alternative option but should be avoided if early pyelonephritis is suspected 1, 2
Critical Pitfall: Trimethoprim-Sulfamethoxazole Resistance
Real-world data demonstrates that TMP/SMX has higher treatment failure rates compared to nitrofurantoin, with a 0.2% increased risk of pyelonephritis and 1.6% increased risk of prescription switch 5. This reflects increasing uropathogen resistance over time 5. Do not use TMP/SMX empirically unless you know local resistance is <20% or the patient has not received it recently 1, 2.
Treatment for Men with Uncomplicated UTI
Men require longer treatment duration than women:
Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is the recommended first-line agent 1
Alternative first-line options include trimethoprim alone or nitrofurantoin for 7 days 3
Always obtain urine culture and susceptibility testing in men before initiating treatment, as urethritis and prostatitis must be considered in the differential diagnosis 3
What to Avoid
Fluoroquinolones should NOT be used for uncomplicated UTI despite their efficacy, due to increasing resistance rates, serious adverse effects (tendon rupture, peripheral neuropathy, QT prolongation), and significant collateral damage in selecting multidrug-resistant organisms 1, 2, 3
β-lactam agents (amoxicillin-clavulanate, cefpodoxime-proxetil) are less effective than first-line agents and should be reserved as alternatives only when first-line options cannot be used 6
When to Obtain Urine Culture
Urine culture is NOT needed for routine uncomplicated UTI in women with typical symptoms 1, 2, 3. Reserve urine culture for:
- Suspected pyelonephritis 1, 2
- Symptoms that don't resolve or recur within 4 weeks after treatment 1, 2
- Atypical symptoms 1
- Pregnant women 1, 2
- All men with UTI symptoms 3
- Recurrent infections 3
- History of resistant isolates 3
Treatment Failure Management
For women whose symptoms don't resolve by end of treatment or recur within 2 weeks:
- Obtain urine culture and antimicrobial susceptibility testing 1
- Retreat with a 7-day regimen using a different antibiotic class 1
- Consider alternative diagnoses if symptoms persist
Special Considerations
Asymptomatic bacteriuria should NOT be treated except in pregnant women or before invasive urologic procedures 1, 2
Routine post-treatment urinalysis or cultures are NOT indicated for asymptomatic patients 1
Women 65 years and older without frailty or relevant comorbidities should receive the same first-line antibiotics and durations as younger adults, but obtain urine culture to adjust therapy based on susceptibility results 3
Women with diabetes presenting with acute cystitis without voiding abnormalities should be treated identically to women without diabetes 3, 6