Simple UTI Management
For uncomplicated cystitis in women, use fosfomycin 3g as a single dose, nitrofurantoin 100mg twice daily for 5 days, or trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days as first-line therapy, with treatment selection based on local resistance patterns. 1
Diagnosis
Women can self-diagnose uncomplicated UTI without office visit or urine culture if they have typical symptoms (frequency, urgency, dysuria, nocturia, suprapubic pain) without vaginal discharge. 2, 3
When to Obtain Urine Culture:
- Suspected acute pyelonephritis 1
- Symptoms not resolving or recurring within 4 weeks after treatment 1
- Atypical symptoms 1
- Pregnant women 1
- Men with UTI symptoms 2
- History of resistant organisms 2
First-Line Treatment Options for Women
The 2024 European Association of Urology guidelines provide the most current recommendations 1:
Preferred Agents:
- Fosfomycin trometamol 3g single dose - most convenient option 1, 4
- Nitrofurantoin 100mg twice daily for 5 days (macrocrystals, monohydrate, or prolonged release formulations) 1
- Pivmecillinam 400mg three times daily for 3-5 days 1
Alternative Agents (when first-line unavailable or contraindicated):
- Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days - only if local E. coli resistance <20% 1, 5
- Trimethoprim 200mg twice daily for 5 days - avoid in first trimester pregnancy 1
- Cephalosporins (e.g., cefadroxil 500mg twice daily for 3 days) - only if local E. coli resistance <20% 1
Fluoroquinolones should be reserved for more invasive infections due to resistance concerns and collateral damage to normal flora. 1, 3
Treatment in Men
Men with uncomplicated UTI require 7 days of treatment, not the shorter courses used in women. 1
- Trimethoprim-sulfamethoxazole 160/800mg twice daily for 7 days 1
- Fluoroquinolones may be used based on local susceptibility testing 1
- Always obtain urine culture in men before initiating treatment 2
- Consider urethritis and prostatitis as alternative diagnoses 2
Symptomatic Treatment Alternative
For women with mild to moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to immediate antimicrobial treatment after shared decision-making. 1 This approach recognizes that complications from untreated simple cystitis are rare, though symptom resolution may be delayed 2.
Treatment Failure Management
If symptoms persist 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 class 1
Post-Treatment Follow-Up
Do not perform routine post-treatment urinalysis or urine cultures in asymptomatic patients. 1 This represents unnecessary testing that does not improve outcomes and may lead to inappropriate treatment of asymptomatic bacteriuria 1.
Key Antibiotic Stewardship Principles
Avoid fluoroquinolones as first-line therapy due to increasing resistance rates and significant collateral damage to normal flora. 1, 6 The AUA/CUA/SUFU guidelines emphasize that while most antibiotics achieve similar clinical cure rates, the concepts of resistance prevalence and collateral damage are critical in choosing UTI treatments 1.
β-lactam agents (amoxicillin-clavulanate, cefpodoxime-proxetil) are less effective as empirical first-line therapies compared to nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole. 3
Special Populations
Women with Diabetes:
Treat similarly to women without diabetes if no voiding abnormalities are present, using the same first-line agents and durations. 3
Elderly Patients (≥65 years):
Obtain urine culture with susceptibility testing to guide therapy, but use the same first-line antibiotics and treatment durations as younger adults. 2
Exercise caution with nitrofurantoin in elderly patients due to potential long-term side effects, particularly with chronic use. 7