What is the treatment for Urinary Tract Infection (UTI)?

From the Guidelines

For uncomplicated urinary tract infections, clinicians should prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim–sulfamethoxazole for 3 days, or fosfomycin as a single dose. This recommendation is based on the best practice advice from the American College of Physicians, as published in the Annals of Internal Medicine in 2021 1. The treatment approach varies depending on the type of UTI, with uncomplicated cystitis and pyelonephritis requiring different durations and types of antibiotics.

Uncomplicated Cystitis

For women with uncomplicated bacterial cystitis, the recommended treatment options include:

• Nitrofurantoin for 5 days
• Trimethoprim–sulfamethoxazole for 3 days
• Fosfomycin as a single dose These options are effective against Escherichia coli, which accounts for more than 75% of all bacterial cystitis cases.

Uncomplicated Pyelonephritis

For men and women with uncomplicated pyelonephritis, the recommended treatment options include:

• Fluoroquinolones for 5 to 7 days
• Trimethoprim–sulfamethoxazole for 14 days The choice of antibiotic should be based on antibiotic susceptibility.

It is essential to note that fluoroquinolones are highly efficacious but have a high propensity for adverse effects, and therefore should not be prescribed empirically. Instead, they should be reserved for patients with a history of resistant organisms. Additionally, patients with symptoms that worsen or include fever, back pain, or nausea/vomiting should seek medical attention immediately, as these may indicate a kidney infection.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to empiric selection of therapy Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris Complicated Urinary Tract Infection and Pyelonephritis – Efficacy in Pediatric Patients: Ciprofloxacin, administered I. V. and/or orally, was compared to a cephalosporin for treatment of complicated urinary tract infections (cUTI) and pyelonephritis in pediatric patients 1 to 17 years of age

UTI Treatment Options:

• Trimethoprim-sulfamethoxazole (PO): can be used to treat urinary tract infections due to susceptible strains of Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris 2.
• Ciprofloxacin (PO): can be used to treat complicated urinary tract infections and pyelonephritis in pediatric patients 1 to 17 years of age, although it is not a drug of first choice in the pediatric population due to an increased incidence of adverse events 3.

From the Research

UTI Treatment Options

• The recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females is a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 4.
• High rates of resistance for trimethoprim-sulfamethoxazole and ciprofloxacin preclude their use as empiric treatment of UTIs in several communities, particularly if patients who were recently exposed to them or in patients who are at risk of infections with extended-spectrum β-lactamases (ESBLs)-producing Enterobacteriales 4.
• Second-line options include oral cephalosporins such as cephalexin or cefixime, fluoroquinolones and β-lactams, such as amoxicillin-clavulanate 4.

Treatment of UTIs Caused by Resistant Bacteria

• Current treatment options for UTIs due to AmpC- β -lactamase-producing Enterobacteriales include nitrofurantoin, fosfomycin, pivmecillinam, fluoroquinolones, cefepime, piperacillin-tazobactam and carbapenems 4.
• Treatment oral options for UTIs due to ESBLs-E coli include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 4.
• Parenteral treatment options for UTIs due to ESBLs-producing Enterobacteriales include piperacillin-tazobactam, carbapenems, ceftazidime-avibactam, ceftolozane-tazobactam, aminoglycosides, cefiderocol, fosfomycin, sitafloxacin, and finafloxacin 4.

Guidelines for UTI Treatment

• The choice of antibiotic substance follows the five primary aspects: individual patient risk and antibiotic pretreatment, bacterial spectrum and antibiotic susceptibility, effectivity of the antimicrobial substance demonstrated in clinical studies, epidemiological effects, and adverse effects 5.
• For empiric therapy of frequent uncomplicated cystitis, fosfomycin-trometamol, nitrofurantoin, or pivmecillinam are recommended as first-line antibiotics 5.
• Asymptomatic bacteriuria should only be treated in exceptional cases, such as pregnant women or prior to expected mucocutaneous traumatising interventions of the urinary tract 5.

Antibiotic Resistance

• Resistance to cotrimoxazole has made the empirical use of this drug problematic in many geographical areas 6.
• If local uropathogen resistance rates to cotrimoxazole exceed 10-25%, empirical cotrimoxazole therapy should not be utilized 6.
• The E. coli species detected in one study were least resistant to fosfomycin (2.4%) 7.
• In the treatment of uncomplicated UTIs, trimethoprim-sulfamethoxazole should be excluded from empirical treatment, while fosfomycin could be a viable option in all age groups 7.