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

Treatment of Urinary Tract Infections

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

Uncomplicated Cystitis in Women

First-Line Treatment Options

• Fosfomycin trometamol: 3g single dose (most convenient option) 1
• Nitrofurantoin: 100mg twice daily for 5 days 1, 2
• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days (only if local E. coli resistance <20%) 1
• Trimethoprim alone: 200mg twice daily for 5 days 1

Alternative Options

• Cephalosporins (e.g., cefadroxil 500mg twice daily for 3 days) if local E. coli resistance <20% 1
• Fluoroquinolones are second-line only due to collateral damage and resistance concerns 1

Key Treatment Principles

• Duration: Keep as short as reasonable, generally no longer than 7 days 1
• Urine culture: NOT needed for straightforward uncomplicated cystitis; reserve for treatment failure, recurrent infections, atypical symptoms, or pregnancy 1, 2
• Symptomatic treatment: NSAIDs (e.g., ibuprofen) may be considered as alternative to antibiotics in mild-moderate cases after shared decision-making 1, 2

Uncomplicated Cystitis in Men

Men require 7-day treatment courses (longer than women due to potential occult prostatitis) 1

• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1, 3
• Fluoroquinolones may be used based on local susceptibility 1
• Always obtain urine culture before treatment in men 2

Uncomplicated Pyelonephritis

Outpatient Oral Treatment

• Ciprofloxacin: 500-750mg twice daily for 7 days 1
• Levofloxacin: 750mg daily for 5 days 1
• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 14 days (only if fluoroquinolone resistance >10%) 1
• Cefpodoxime: 200mg twice daily for 10 days 1

Inpatient IV Treatment

For patients requiring hospitalization, start with IV therapy then transition to oral 1:

• Ciprofloxacin: 400mg IV twice daily 1
• Levofloxacin: 750mg IV daily 1
• Ceftriaxone: 1-2g IV daily 1
• Cefepime: 1-2g IV twice daily 1
• Piperacillin-tazobactam: 2.5-4.5g IV three times daily 1

Reserve carbapenems and novel agents only for multidrug-resistant organisms confirmed by early culture results 1

Complicated UTI

Complicated UTI requires broader empiric coverage with combination therapy and always obtain urine culture before treatment 1

Defining Features of Complicated UTI

Any of the following factors make a UTI "complicated" 1:

• Male sex
• Pregnancy
• Urinary obstruction
• Foreign body/catheter
• Incomplete voiding
• Vesicoureteral reflux
• Recent instrumentation
• Diabetes mellitus
• Immunosuppression
• Healthcare-associated infection
• ESBL or multidrug-resistant organisms

Empiric Treatment for Complicated UTI with Systemic Symptoms

Use combination IV therapy 1:

• Amoxicillin PLUS aminoglycoside, OR
• Second-generation cephalosporin PLUS aminoglycoside, OR
• Third-generation cephalosporin IV (monotherapy)

Duration

• 7-14 days depending on clinical response 1
• 14 days for men when prostatitis cannot be excluded 1
• May shorten to 7 days if hemodynamically stable and afebrile ≥48 hours 1

Fluoroquinolone Restrictions in Complicated UTI

Only use ciprofloxacin if 1:

• Local resistance <10%, AND
• Entire treatment can be oral, AND
• Patient doesn't require hospitalization, AND
• Patient has anaphylaxis to β-lactams

Do NOT use fluoroquinolones if 1:

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

Recurrent UTI Prevention

Non-Antimicrobial Prophylaxis (Try First)

• Vaginal estrogen in postmenopausal women (strong recommendation) 1
• Increased fluid intake in premenopausal women 1
• Methenamine hippurate for women without urinary tract abnormalities 1, 2
• Immunoactive prophylaxis (all age groups) 1
• Cranberry products (weak evidence, patient preference) 1
• D-mannose (weak/contradictory evidence) 1
• Probiotics with proven vaginal flora strains 1

Antimicrobial Prophylaxis (When Non-Antimicrobial Fails)

• Use continuous or postcoital prophylaxis only after non-antimicrobial interventions fail 1
• Counsel patients on side effects and resistance risks 1

Critical Pitfalls to Avoid

1. Do NOT treat asymptomatic bacteriuria (except in pregnancy or before urologic procedures) 1
2. Do NOT obtain post-treatment cultures in asymptomatic patients 1
3. Do NOT use single-dose therapy (associated with higher treatment failure) 1
4. Do NOT use fluoroquinolones empirically for complicated UTI in urology patients or recent fluoroquinolone users 1
5. Do NOT skip urine culture in men, complicated UTI, pyelonephritis, treatment failure, or recurrent infections 1
6. Do NOT perform extensive workup (cystoscopy, imaging) in women <40 years with recurrent UTI and no risk factors 1

Treatment Failure Management

If symptoms persist after treatment 1:

• Obtain urine culture and susceptibility testing 1
• Assume organism not susceptible to original agent 1
• Retreat with 7-day course using different antibiotic class 1
• Consider imaging if rapid recurrence with same organism or struvite-forming bacteria (e.g., Proteus) 1