What is the recommended treatment for symptoms of a urinary tract infection (UTI)?

Treatment of Urinary Tract Infection Symptoms

For uncomplicated UTI in women with typical symptoms (dysuria, frequency, urgency), first-line treatment is nitrofurantoin 100 mg twice daily for 5 days, fosfomycin 3 g single dose, or trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days—no urine culture is needed before starting treatment unless there are complicating factors. 1

Diagnostic Approach

When to Diagnose Without Testing

• Women with acute-onset dysuria plus frequency/urgency and no vaginal discharge can be diagnosed clinically without urinalysis or culture 1
• Dysuria has >90% accuracy for UTI in young women when vaginal symptoms are absent 1
• Dipstick testing adds minimal diagnostic value when symptoms are typical 1

When Urine Culture IS Required

Obtain culture before treatment in these situations: 1

• Suspected pyelonephritis (fever, flank pain)
• Symptoms persisting or recurring within 4 weeks of treatment
• Atypical presentation
• Pregnancy
• Men with any UTI symptoms 2
• Recurrent UTI patients 1
• Adults ≥65 years old 2

First-Line Antibiotic Treatment

For Women with Uncomplicated Cystitis

Preferred options: 1

• Fosfomycin trometamol 3 g single dose (1 day treatment)
• Nitrofurantoin 100 mg twice daily for 5 days
• Pivmecillinam 400 mg three times daily for 3-5 days

Alternative options (if local E. coli resistance <20%): 1

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

For Men with Uncomplicated UTI

Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is the primary recommendation 1, 2

• Fluoroquinolones can be used based on local susceptibility 1
• Always obtain urine culture in men to guide therapy 2
• Consider prostatitis if symptoms persist—may require 14 days of treatment 1

Complicated UTI Treatment

When UTI is Complicated

Complicating factors include: 1

• Male sex
• Urinary obstruction or foreign body
• Pregnancy
• Diabetes mellitus
• Immunosuppression
• Recent instrumentation
• Healthcare-associated infection
• Catheter use (current or within 48 hours) 1

Empiric Treatment for Complicated UTI with Systemic Symptoms

Use combination IV therapy: 1

• Amoxicillin plus aminoglycoside, OR
• Second-generation cephalosporin plus aminoglycoside, OR
• Third-generation cephalosporin IV

Duration: 7-14 days (14 days for men when prostatitis cannot be excluded) 1

• May shorten to 7 days if hemodynamically stable and afebrile ≥48 hours 1

Critical Fluoroquinolone Restrictions

Do NOT use ciprofloxacin/fluoroquinolones for empiric complicated UTI if: 1

• Patient is from urology department
• Fluoroquinolone use in last 6 months
• Local resistance rate >10%

Only use ciprofloxacin when: 1

• Entire treatment is oral AND
• Patient doesn't require hospitalization AND
• Patient has anaphylaxis to β-lactams

Special Populations

Older Adults (≥65 years)

• Atypical presentations are common: altered mental status, functional decline, falls, fatigue 1
• Must have recent-onset dysuria OR systemic signs (fever >37.8°C, rigors, clear delirium) to diagnose UTI 1
• Obtain urine culture before treatment 1, 2
• Same antibiotic choices and durations as younger adults 1, 2
• Do not treat based solely on: cloudy urine, odor, nocturia, suprapubic discomfort, or chronic symptoms 1

Catheter-Associated UTI

• Treat according to complicated UTI recommendations 1
• Mortality risk is approximately 10% for associated bacteremia 1
• Always obtain culture before starting antibiotics 1

Non-Antibiotic Considerations

Symptomatic Treatment

For mild-to-moderate symptoms, ibuprofen alone may be considered as alternative to antibiotics after patient discussion 1

• Risk of complications is low with expectant management 2
• Delayed antibiotic approach is reasonable while awaiting cultures 1

Management of Underlying Factors

Mandatory to address urological abnormalities or complicating factors 1

• Treatment duration should relate to correction of underlying abnormality 1

Common Pitfalls to Avoid

• Do not obtain routine cultures for typical uncomplicated cystitis in women—this adds unnecessary cost 1, 4
• Do not treat asymptomatic bacteriuria except in pregnancy or before urological procedures breaching mucosa 1
• Do not use single-dose therapy—3-5 day courses have better eradication rates 4, 2
• Do not diagnose UTI in elderly based on chronic symptoms or urine appearance alone—requires acute-onset dysuria or systemic signs 1
• Avoid fluoroquinolones as first-line due to resistance patterns and side effect profile 1