What are the management options for urinary tract infections (UTIs)?

Management of Urinary Tract Infections

Empirical Treatment for Acute UTI

For uncomplicated cystitis in adult women, nitrofurantoin 100 mg twice daily for 5 days is the preferred first-line agent, as it demonstrates robust efficacy while sparing broader-spectrum antibiotics and maintaining low resistance rates. 1, 2, 3

First-Line Treatment Options for Uncomplicated Cystitis

• Nitrofurantoin: 50-100 mg twice daily for 5 days is the drug of choice based on excellent efficacy, low resistance rates, and antimicrobial stewardship principles 1, 2, 4

  • Achieves bacteriological cure in 81% of patients by day 3 versus 20% with placebo 5
  • Should NOT be used for febrile UTIs or pyelonephritis as it does not achieve adequate tissue concentrations 1

• Fosfomycin trometamol: Single 3-gram dose offers convenience and effectiveness 1, 3, 4

• Trimethoprim-sulfamethoxazole (TMP/SMX): 160/800 mg (one double-strength tablet) twice daily for 3 days 1, 6, 3

  • Only use if local resistance rates are <20% 1, 4
  • Check local antibiogram before prescribing 1

• Pivmecillinam: 3 days of therapy for uncomplicated cystitis 1

Second-Line and Alternative Agents

• Fluoroquinolones: 3 days for cystitis, but should be reserved for more invasive infections due to resistance concerns and adverse effects 1, 3, 7

  • Not recommended as first-line due to inappropriately excessive utilization 8

• β-lactams (amoxicillin-clavulanate, cefpodoxime): Less effective as empirical first-line therapy compared to other options 1, 3

Treatment for Pyelonephritis

For patients requiring intravenous therapy, ceftriaxone 75 mg/kg every 24 hours is the recommended empirical choice for pyelonephritis, unless risk factors for multidrug resistance exist. 1

Oral Options for Pyelonephritis (when appropriate)

• TMP/SMX or first-generation cephalosporins are reasonable first-line oral agents, dependent on local resistance rates 1

• Duration: 7-14 days total therapy (intravenous plus oral combined) 1

  • For men, use 14 days when prostatitis cannot be excluded 2

Parenteral Options

• Ceftriaxone: 75 mg/kg every 24 hours 1
• Cefotaxime: 150 mg/kg/day divided every 6-8 hours 1
• Gentamicin: 7.5 mg/kg/day divided every 8 hours 1

Switch to oral therapy once clinical improvement occurs (typically 24-48 hours) and patient can retain oral medications. 1

Special Populations

Pediatric Patients (2-24 months with febrile UTI)

• Oral therapy is appropriate for most febrile infants unless they appear toxic or cannot retain oral intake 1
• Oral options include cephalosporins, amoxicillin-clavulanate (20-40 mg/kg/day in 3 doses), or TMP/SMX (based on local susceptibility) 1
• Total duration: 7-14 days 1
• Avoid nitrofurantoin in febrile pediatric UTIs as it doesn't achieve adequate parenchymal concentrations 1

Men with UTI

• Duration: 7-14 days based on limited observational data 2, 3
• Use 14 days when prostatitis cannot be excluded 2

Women with Diabetes

• Treat similarly to women without diabetes when presenting with acute cystitis and no voiding abnormalities 2, 3

Complicated UTIs

• Duration: 7-14 days 2
• Address underlying urological abnormalities or complicating factors 2
• Tailor therapy based on culture results and local resistance patterns 2

Catheter-Associated UTI (CAUTI)

• Urinalysis has very low specificity in patients with indwelling catheters but excellent negative predictive value 1

  • A negative UA can rule out CAUTI 1
  • A positive UA does NOT confirm CAUTI due to universal bacteriuria in chronic catheterization 1

• Remove or change the catheter when clinically feasible as part of management 2

• Obtain cultures and tailor therapy based on susceptibility 2

Prevention of Recurrent UTIs

For postmenopausal women with recurrent UTIs, vaginal estrogen therapy is highly effective and should be offered as first-line prevention. 1, 2

Non-Antibiotic Prevention Strategies (Preferred)

• Vaginal estrogen (rings, inserts, or cream): Reduces recurrent UTIs in postmenopausal women based on 30 RCTs 1, 2

  • Minimal systemic absorption with no concerning safety signals for stroke, VTE, breast cancer, colorectal cancer, or endometrial cancer 1
  • May be used with or without lactobacillus-containing probiotics 2

• Methenamine hippurate: 1 gram twice daily is an antimicrobial-sparing option for patients without incontinence and fully functional bladder 1, 2

• Cranberry products: 100-500 mg daily containing proanthocyanidin 36 mg can reduce recurrent UTIs in women and children 1, 2

• Increased water intake: Additional 1.5 liters daily shown to decrease UTIs in one RCT among healthy women 1

Antibiotic Prophylaxis (When Non-Antibiotic Options Fail)

• Daily nitrofurantoin prophylaxis: 50-100 mg daily is most effective, reducing UTI rate to 0.4/year 2

• Post-coital prophylaxis: TMP/SMX 40/200 mg or 80/400 mg single dose within 2 hours of intercourse for 6-12 months in premenopausal women 1, 2

• Continuous prophylaxis: TMP/SMX 40/200 mg once daily or three times weekly 1

Balance antibiotic prophylaxis against risks of adverse drug events, antimicrobial resistance, and microbiome disruption. 1

Critical Pitfalls to Avoid

• Never treat asymptomatic bacteriuria in women with recurrent UTIs, as this fosters resistance and increases recurrence 2

• Do not use nitrofurantoin for febrile UTIs or pyelonephritis due to inadequate tissue penetration 1

• Avoid broad-spectrum antibiotics (especially fluoroquinolones) for uncomplicated cystitis to preserve their effectiveness for serious infections 1, 3, 7

• Do not rely on positive UA alone to diagnose CAUTI in catheterized patients 1

• Obtain urine culture before treatment when possible to guide targeted therapy and track resistance patterns 1, 2

Self-Start Therapy

• Consider for reliable patients who can obtain pre-treatment urine specimens and communicate effectively with providers 2
• Provide clear instructions on when to initiate therapy and when to seek medical attention 2
• Ensure patient obtains urine culture before starting antibiotics 2

Imaging Considerations

• Renal and bladder ultrasonography should be performed in febrile infants with UTIs to detect anatomic abnormalities 1

• Contrast CT is best for detecting kidney abscesses in complicated cases, though discussion with radiology is recommended 1

• Only obtain imaging if results will alter management for patients with known or suspected UTI 1