What is the standard treatment for an uncomplicated urinary tract infection (UTI)?

Standard Treatment for Uncomplicated Urinary Tract Infection

For uncomplicated cystitis in women, use nitrofurantoin (50-100mg four times daily for 5 days), fosfomycin trometamol (3g single dose), or trimethoprim-sulfamethoxazole (160/800mg twice daily for 3 days) as first-line therapy, with the specific choice guided by your local antibiogram and resistance patterns. 1

First-Line Antibiotic Options

The three recommended first-line agents are selected specifically because they effectively treat UTI while minimizing collateral damage (disruption of normal flora and promotion of resistance) compared to broader-spectrum alternatives 2:

• Nitrofurantoin macrocrystals: 50-100mg four times daily for 5 days 1
• Fosfomycin trometamol: 3g as a single dose 1
• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days, but ONLY if local resistance rates are <20% 1

Critical Decision Points Based on Local Resistance

Your choice among these three agents must be guided by your local antibiogram 2, 1:

• If trimethoprim-sulfamethoxazole resistance exceeds 20% in your area, do not use it empirically 1
• Fluoroquinolones should be avoided for empiric treatment if local resistance exceeds 10% or if the patient used fluoroquinolones in the past 6 months 1
• Fluoroquinolones are no longer recommended as first-line therapy for uncomplicated cystitis due to resistance concerns and collateral damage 2

Treatment Duration

Treat for as short a duration as reasonable, generally no longer than 7 days 2:

• Three-day courses are the accepted standard for uncomplicated cystitis 2
• Five-day courses are appropriate for nitrofurantoin 1
• Single-dose therapy is effective for fosfomycin 1

Shorter durations are preferred to limit development of resistance 2.

When to Obtain Urine Culture

For typical uncomplicated cystitis with classic symptoms (dysuria, frequency, urgency), urine culture is NOT required before initiating treatment 1:

• Diagnosis can be made with high probability based on focused history alone when symptoms are typical and vaginal discharge is absent 1
• Urine culture IS recommended when: symptoms do not resolve or recur within 4 weeks after treatment, symptoms are atypical, the patient is pregnant, or this represents recurrent UTI 1
• For recurrent UTI patients (≥3 UTIs per year or 2 UTIs in last 6 months), obtain culture with each symptomatic episode before initiating treatment 2, 1

Alternative Non-Antibiotic Approach

For women with mild to moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to antimicrobial treatment after discussing risks and benefits with the patient 1. This approach helps reduce unnecessary antibiotic exposure.

Critical Pitfalls to Avoid

• Never treat asymptomatic bacteriuria (except in pregnancy or before invasive urological procedures) - this promotes antimicrobial resistance without clinical benefit 2, 1
• Avoid broad-spectrum antibiotics when narrower options are available 1
• Do not perform routine post-treatment urinalysis or cultures in asymptomatic patients 1
• Do not use surveillance urine testing in asymptomatic patients with history of recurrent UTI 2

When Treatment Fails

If symptoms do not resolve by the end of treatment or recur within 2 weeks, obtain urine culture and antimicrobial susceptibility testing 1. This guides targeted therapy and identifies potential resistance patterns.