What is the treatment for an uncomplicated urinary tract infection (UTI)?

Treatment of Uncomplicated Urinary Tract Infection

For uncomplicated UTI in women, first-line treatment consists of nitrofurantoin (100 mg twice daily for 5 days), fosfomycin trometamol (3g single dose), or trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days if local E. coli resistance is <20%). 1, 2

Diagnosis and When to Obtain Cultures

• In women with typical symptoms (dysuria, frequency, urgency, suprapubic pain) without vaginal discharge, clinical diagnosis alone is sufficient to initiate treatment without urine culture 1, 3
• Obtain urine culture before treatment in these situations: suspected pyelonephritis, symptoms not resolving or recurring within 4 weeks, atypical symptoms, pregnancy, recurrent UTIs, or history of resistant organisms 1, 2
• Dipstick testing adds minimal diagnostic value when symptoms are typical but can be helpful if the diagnosis is unclear 1

First-Line Antibiotic Options for Women

The 2024 European Association of Urology guidelines provide the most current recommendations:

Preferred first-line agents:

• Fosfomycin trometamol: 3g single dose 1, 2
• Nitrofurantoin: 100 mg twice daily for 5 days (or 50-100 mg four times daily for 5 days) 1, 2
• Pivmecillinam: 400 mg three times daily for 3-5 days 1

Alternative agents (if local E. coli resistance <20%):

• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days 1, 2, 4
• Trimethoprim alone: 200 mg twice daily for 5 days 1
• Cephalosporins (e.g., cefadroxil): 500 mg twice daily for 3 days 1

Treatment Duration

• Keep antibiotic courses as short as reasonable, generally no longer than 7 days 2
• Three to five-day regimens are preferred over single-dose therapy (except fosfomycin) because single-dose antibiotics have higher bacteriological failure rates 2, 5
• While 3-day therapy has similar symptomatic cure rates to 5-10 day therapy, longer courses achieve better bacteriological eradication 5

Treatment in Men

• All men with UTI symptoms require urine culture and susceptibility testing before or concurrent with treatment 3
• Consider urethritis and prostatitis as alternative diagnoses 3
• First-line options: trimethoprim-sulfamethoxazole (160/800 mg twice daily for 7 days), trimethoprim, or nitrofurantoin for 7 days 1, 3
• Fluoroquinolones can be prescribed based on local susceptibility patterns 1

What to Avoid

• Do not use fluoroquinolones as first-line agents due to unfavorable risk-benefit ratio, collateral damage to normal flora, and increasing resistance 2, 6
• Avoid broad-spectrum antibiotics when narrower-spectrum options are effective 2
• Do not treat asymptomatic bacteriuria except in pregnancy or before invasive urinary procedures 2
• Do not perform routine post-treatment cultures in asymptomatic patients 1

Alternative to Antibiotics

• For women with mild to moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to immediate antibiotic treatment after discussing risks and benefits 1, 7
• The risk of uncomplicated UTI progressing to pyelonephritis is low (1-2%) 7

Treatment Failure

• If symptoms persist at end of treatment or recur within 2 weeks, obtain urine culture and susceptibility testing 1
• Assume the organism is not susceptible to the original agent 1
• Retreat with a 7-day course using a different antibiotic 1

Key Pitfalls to Avoid

• Do not treat based on positive urine culture alone without symptoms - this leads to unnecessary antibiotic exposure, increased resistance, and paradoxically higher rates of symptomatic infection 2
• Do not skip culture in recurrent UTIs - this leads to inappropriate antibiotic selection and treatment failure 2
• Consider local antibiogram patterns when selecting empiric therapy 2
• Select agents with minimal impact on vaginal and fecal flora to reduce recurrence risk 2