Treatment of Uncomplicated UTI in Females
Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is the preferred first-line treatment for acute uncomplicated cystitis in women. 1, 2
First-Line Treatment Options
The following agents are recommended as first-line therapy, listed in order of preference based on resistance patterns and collateral damage considerations:
Nitrofurantoin (Preferred)
- Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days 1, 2
- Achieves 90% early clinical cure and 84% late clinical cure rates 1
- Minimal resistance and lowest propensity for collateral damage (antimicrobial resistance in other body sites) 1
- Avoid if early pyelonephritis is suspected as it does not achieve adequate tissue concentrations 1, 2
Trimethoprim-Sulfamethoxazole (TMP-SMX)
- TMP-SMX 160/800 mg (one double-strength tablet) twice daily for 3 days 1, 3
- Only use if local E. coli resistance rates are below 20% 1, 2
- Achieves 90% early clinical cure and 79% late clinical cure rates 1
- Do not use if the patient received TMP-SMX for UTI in the previous 3 months 1
- When resistance exceeds 20%, clinical cure drops dramatically to 41% versus 84% with susceptible organisms 1
Fosfomycin
- Fosfomycin trometamol 3 g single dose 1, 2
- Minimal resistance and collateral damage 1
- Has inferior efficacy compared to nitrofurantoin and TMP-SMX (approximately 5-10% lower cure rates) 1
- Avoid if early pyelonephritis is suspected 1, 2
Second-Line Alternatives
Use these agents only when first-line options cannot be used due to allergy, intolerance, or resistance:
Fluoroquinolones
- Ciprofloxacin, levofloxacin, or ofloxacin for 3 days 1
- Highly efficacious (95% cure rates) 1
- Should be reserved for more serious infections due to high propensity for collateral damage and increasing resistance 1
- FDA has issued serious safety warnings regarding tendon, muscle, joint, nerve, and CNS effects 2
Beta-Lactams
- Amoxicillin-clavulanate, cefdinir, cefaclor, or cefpodoxime-proxetil for 3-7 days 1
- Less effective than first-line agents with more adverse effects 1
- Do not use amoxicillin or ampicillin alone due to poor efficacy and high resistance rates 2
Treatment Duration
- Nitrofurantoin: 5 days 1, 2
- TMP-SMX: 3 days 1
- Fosfomycin: Single dose 1
- Fluoroquinolones: 3 days 1
- Beta-lactams: 3-7 days 1
- Generally, no treatment should exceed 7 days for uncomplicated cystitis 1
Diagnostic Considerations
When to Obtain Urine Culture
- Not necessary before starting empiric therapy in straightforward uncomplicated UTI 2
- Obtain culture in patients with: 1
- Recurrent UTIs (before each episode)
- Treatment failure
- History of resistant organisms
- Atypical presentation
Clinical Diagnosis
- Self-diagnosis with typical symptoms (frequency, urgency, dysuria, nocturia, suprapubic pain) without vaginal discharge is sufficiently accurate to start treatment without testing 4
- Presence of fever or flank pain suggests pyelonephritis, not uncomplicated cystitis—requires different management 1
Critical Pitfalls to Avoid
Do not use TMP-SMX empirically in areas with >20% E. coli resistance or in patients recently treated with it—failure rates exceed 50% 1
Do not use nitrofurantoin or fosfomycin if pyelonephritis is suspected—these agents do not achieve adequate tissue concentrations 1, 2
Do not treat asymptomatic bacteriuria (except in pregnancy or before urologic procedures)—treatment does not improve outcomes and promotes resistance 1, 2
Do not perform surveillance urine cultures in asymptomatic patients with history of recurrent UTIs 1, 2
Avoid fluoroquinolones as first-line therapy—reserve for more serious infections to minimize resistance development and serious adverse effects 1, 2