Treatment of Uncomplicated Urinary Tract Infections
For uncomplicated UTIs in women, 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 following agents are recommended as first-line therapy for uncomplicated cystitis in women:
Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is a preferred first-line agent with minimal resistance rates and low propensity for collateral damage (selection of resistant organisms) 1, 2
Fosfomycin trometamol 3 g as a single dose offers the convenience of single-dose therapy, though it has slightly lower efficacy than other first-line agents 1, 2
Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days should only be used if local E. coli resistance rates are <20% or if the infecting strain is known to be susceptible 1, 2, 3
Pivmecillinam 400 mg three times daily for 3-5 days is an alternative in regions where available, though it has lower efficacy than some other recommended agents 1, 2
When to Avoid Certain Antibiotics
Fluoroquinolones should be reserved for more invasive infections (such as pyelonephritis or complicated UTIs) rather than uncomplicated cystitis, despite their effectiveness, due to concerns about collateral damage and the need to preserve these agents for serious infections 1, 4, 5
Fluoroquinolones and third-generation cephalosporins select for multidrug-resistant pathogens and should not be used as first-line therapy for simple cystitis 4, 6
Beta-lactam agents (amoxicillin-clavulanate, cephalexin, cefpodoxime) are less effective as empirical first-line therapies compared to the recommended agents 5
Diagnostic Approach
Urine culture is not routinely needed for typical uncomplicated cystitis in women. 1, 7
Obtain urine culture and susceptibility testing only in these specific situations:
- Suspected acute pyelonephritis 1
- Symptoms that do not resolve or recur within 4 weeks after completing treatment 1
- Women presenting with atypical symptoms 1
- Pregnant women 1
- History of resistant isolates or recent antibiotic exposure 7
- Treatment failure 7
Women can accurately self-diagnose UTI when typical symptoms are present (dysuria, frequency, urgency, suprapubic pain) without vaginal discharge, making diagnosis possible without an office visit 7, 5
Treatment Duration
Treat uncomplicated cystitis with as short a duration as reasonable, generally no longer than 7 days. 1
- 3-day regimens are appropriate for trimethoprim-sulfamethoxazole 1, 5
- 5-day regimens are standard for nitrofurantoin 1, 5
- Single-dose therapy with fosfomycin is acceptable 1, 5
Single-dose antibiotics are associated with increased risk of bacteriological persistence compared to 3-6 day courses 1
Special Populations
Men with Uncomplicated UTI
- Men should always receive antibiotics and require urine culture with susceptibility testing 7
- First-line options include trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days or nitrofurantoin for 7 days 1, 7
- Consider urethritis and prostatitis as alternative diagnoses in men with UTI symptoms 7
- Treatment duration is 7 days for uncomplicated UTI in men 1, 7
Older Adults (≥65 years)
- Nonfrail older adults with no relevant comorbidities should receive the same first-line antibiotics as younger adults 7
- Obtain urine culture with susceptibility testing to adjust therapy after initial empiric treatment 7
- Treatment durations do not differ from younger adults 7
Women with Diabetes
- Women with diabetes without voiding abnormalities should be treated similarly to women without diabetes 5
- Use the same first-line agents and durations 5
Alternative to Immediate Antibiotics
For women with mild to moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to immediate antimicrobial treatment after discussing risks and benefits with the patient. 1
- However, immediate antimicrobial therapy is generally recommended over delayed treatment or symptom management alone 5
- The risk of complications from untreated uncomplicated cystitis is low 7
Asymptomatic Bacteriuria
Do not screen for or treat asymptomatic bacteriuria except in pregnant women or before invasive urologic procedures. 1, 2
- Treatment of asymptomatic bacteriuria increases antimicrobial resistance without clinical benefit 2
- Surveillance urine testing should be omitted in asymptomatic patients, including those with recurrent UTIs 1
Common Pitfalls to Avoid
Do not use trimethoprim-sulfamethoxazole empirically if the patient has received it recently or if local resistance rates exceed 20%, as prior exposure significantly increases resistance risk 4, 6
Avoid routine post-treatment urine cultures in asymptomatic patients, as they are not indicated and may lead to unnecessary treatment of asymptomatic bacteriuria 1
Do not prescribe fluoroquinolones for simple cystitis when first-line agents are appropriate, to preserve their effectiveness for serious infections and minimize collateral damage 1, 4, 6