Treatment for Uncomplicated Urinary Tract Infection
For uncomplicated UTI in women, nitrofurantoin 100 mg twice daily for 5 days is the recommended first-line treatment, with fosfomycin 3 g single dose or trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days as alternatives if local resistance rates are acceptable. 1
First-Line Antibiotic Options for Women
The European Association of Urology 2024 guidelines prioritize agents with minimal resistance patterns and low collateral damage 1:
Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days - preferred due to minimal resistance and low propensity for selecting multidrug-resistant organisms 1, 2
Fosfomycin trometamol 3 g single dose - convenient single-dose regimen, though slightly lower efficacy than nitrofurantoin 1, 3
Pivmecillinam 400 mg three times daily for 3-5 days - effective option but should be avoided if early pyelonephritis is suspected 1
Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days - only if local E. coli resistance rates are <20% AND the patient hasn't used it for UTI in the previous 3 months 1, 2
Critical Pitfall: Fluoroquinolone Overuse
Fluoroquinolones should be avoided for uncomplicated UTIs despite their effectiveness, due to increasing resistance rates, significant collateral damage (selection of multidrug-resistant organisms), and risk of serious adverse effects 1, 4. Reserve these agents for complicated infections and pyelonephritis 5.
Treatment for Men with Uncomplicated UTI
Men require longer treatment duration than women 5:
Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is the recommended first-line agent 1
Alternative options include trimethoprim or nitrofurantoin for 7 days 2
Always obtain urine culture and susceptibility testing in men before initiating treatment, as prostatitis must be excluded (which would require 14 days of therapy) 5, 2
Consider urethritis as an alternative diagnosis in men presenting with UTI symptoms 2
When to Obtain Urine Culture
Urine culture is NOT needed for routine uncomplicated cystitis in women with typical symptoms 1, 2. Reserve cultures for:
- Suspected pyelonephritis 1
- Symptoms that don't resolve or recur within 4 weeks after treatment 1
- Atypical symptoms 1
- Pregnant women 1
- All men with UTI symptoms 2
- Women with recurrent UTI (≥3 UTIs/year or ≥2 UTIs in 6 months) 1
- History of resistant isolates 2
Antibiotic Selection Algorithm
When choosing empiric therapy, consider these factors in order 1:
Local resistance patterns - particularly for trimethoprim-sulfamethoxazole (use only if <20% resistance) 1, 4
Recent antibiotic exposure - if patient received trimethoprim-sulfamethoxazole or fluoroquinolones in past 3 months, risk of resistance is significantly increased 4
Patient's allergy history 1
Renal function - nitrofurantoin requires adequate creatinine clearance 1
Pregnancy status - trimethoprim should not be used in first trimester 1
Alternative Second-Line Options
If first-line agents are contraindicated or unavailable 1, 6:
Cephalosporins (cefadroxil) 500 mg twice daily for 3 days - only if local E. coli resistance is <20% 1
Trimethoprim 200 mg twice daily for 5 days - avoid in first trimester of pregnancy 1
Note that β-lactam agents (amoxicillin-clavulanate, cefpodoxime-proxetil) are less effective as empirical first-line therapies 3
Treatment Failure Management
For women whose symptoms don't resolve by end of treatment or recur within 2 weeks 1:
- Obtain urine culture and antimicrobial susceptibility testing 1
- Retreat with a 7-day regimen using a different antibiotic class 1
- Consider possibility of resistant organism or complicated UTI 2
Important Clinical Considerations
Do NOT treat asymptomatic bacteriuria except in pregnant women or before urologic procedures with expected mucosal trauma 1, 4. Treating asymptomatic bacteriuria leads to unnecessary antibiotic exposure and promotes resistance 4.
Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1.
Diagnosis in women with typical symptoms (frequency, urgency, dysuria, nocturia, suprapubic pain) without vaginal discharge is accurate enough to diagnose uncomplicated UTI without office visit or testing 2, 3.
Special Populations
Women with diabetes and uncomplicated cystitis should be treated similarly to women without diabetes, using the same first-line agents and durations, provided they have no voiding abnormalities 3.
Older adults (≥65 years) require urine culture with susceptibility testing to adjust antibiotic choice after initial empiric treatment, but first-line antibiotics and treatment durations remain the same as for younger adults 2.