Treatment of Uncomplicated Urinary Tract Infection
For an uncomplicated UTI, use nitrofurantoin 100 mg twice daily for 5 days, fosfomycin 3 g single dose, or trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days as first-line therapy, with the choice depending on local resistance patterns. 1, 2
First-Line Antibiotic Options
The three recommended first-line agents are selected based on their efficacy and minimal collateral damage to the microbiome: 1
Nitrofurantoin monohydrate/macrocrystals: 100 mg twice daily for 5 days—this agent has minimal resistance patterns (only 2.6% prevalence at initial infection, 5.7% at 9 months) and low propensity for collateral damage 1, 2, 3
Fosfomycin trometamol: 3 g as a single dose—offers the convenience of single-dose therapy, though with slightly lower efficacy than other first-line agents 2, 3, 4
Trimethoprim-sulfamethoxazole (TMP-SMX): 160/800 mg twice daily for 3 days—use only if local resistance rates are <20% or if the infecting strain is known to be susceptible 1, 2, 3
Critical Antibiotic Stewardship Principles
Avoid fluoroquinolones for uncomplicated UTIs. The FDA issued an advisory in 2016 warning against fluoroquinolone use for uncomplicated UTIs due to disabling and serious adverse effects that create an unfavorable risk-benefit ratio. 1 These agents, along with cephalosporins, are more likely to alter fecal microbiota, cause Clostridium difficile infection, and promote more rapid UTI recurrence. 1
Beta-lactam antibiotics are not first-line therapy because of collateral damage effects and their propensity to promote more rapid recurrence of UTI. 1
Treatment Duration
Treat for as short a duration as reasonable, generally no longer than 7 days. 1 For uncomplicated cystitis specifically, 3-5 days of treatment typically suffices with the first-line agents listed above. 2, 5, 3
When to Obtain Urine Culture
For initial uncomplicated UTI in women, urine culture is not routinely needed if symptoms are typical (frequency, urgency, dysuria, nocturia, suprapubic pain without vaginal discharge). 3 Self-diagnosis with typical symptoms is accurate enough to proceed with empiric treatment. 3
Obtain urine culture and sensitivity testing before treatment in these situations: 1, 2
- Recurrent UTIs (≥3 UTIs per year or ≥2 UTIs in 6 months) 1, 2
- Treatment failure or symptoms persisting/recurring within 4 weeks 2
- History of resistant isolates 3
- Atypical presentation 3
- Suspected pyelonephritis 2
Common Pitfalls to Avoid
Do not treat asymptomatic bacteriuria. Treatment of asymptomatic bacteriuria increases the risk of symptomatic infection, bacterial resistance, and healthcare costs—the only exceptions are pregnant women and patients before invasive urologic procedures. 1, 2
Do not perform surveillance urine testing in asymptomatic patients with recurrent UTIs. 1 Without symptoms, any magnitude of bacteriuria is considered asymptomatic and should not be treated. 1
Recognize high resistance patterns in your community. In some cohorts, there is high likelihood of persistent resistance to ampicillin (84.9%), amoxicillin-clavulanate (54.5%), ciprofloxacin (83.8%), and TMP (78.3%), which makes knowledge of local antibiograms essential. 1
Alternative Approach: Symptomatic Treatment
For women with mild to moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to antimicrobials. 2 The risk of an uncomplicated UTI progressing to pyelonephritis is low (1-2%), and starting with pain relief while awaiting the course of infection without antibiotics is a reasonable approach in select cases. 5