What is the recommended treatment for urinary tract infections (UTIs)?

Treatment of Urinary Tract Infections

For acute uncomplicated UTI in women, initiate empiric therapy with nitrofurantoin (100 mg twice daily for 5-7 days), trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), or fosfomycin (3 g single dose) based on local resistance patterns, with nitrofurantoin preferred when resistance data is unavailable. 1, 2

Uncomplicated UTI in Women

First-Line Empiric Treatment

• Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5-7 days is the preferred first-line agent due to low resistance rates and minimal collateral damage 1, 2
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days is appropriate only if local resistance rates are <20% 2
• Fosfomycin trometamol 3 g as a single dose is an effective alternative 2

Second-Line Options

• Oral cephalosporins (cephalexin, cefixime) or amoxicillin-clavulanate (20-40 mg/kg per day in 3 doses) when first-line agents are contraindicated 1, 3
• Avoid fluoroquinolones for uncomplicated cystitis—reserve these for complicated infections or pyelonephritis 1
• β-lactam agents are less effective than first-line therapies and should not be used empirically 2

Critical Management Principles

• Obtain urine culture before treatment only if: patient has recurrent UTI, symptoms persist despite treatment, or complicated factors are present 1
• Do NOT treat asymptomatic bacteriuria in women with recurrent UTI, as this increases antimicrobial resistance and recurrence rates 1
• Consider self-start therapy in reliable patients who can obtain urine specimens before starting antibiotics 1

Complicated UTI

Definition and Risk Factors

Reserve "complicated UTI" classification for patients with: 1

• Structural/functional urinary tract abnormalities
• Immunosuppression or pregnancy
• Male gender
• Recent instrumentation or catheterization
• Diabetes mellitus
• Healthcare-associated infections
• Multidrug-resistant organisms

Empiric Treatment for Complicated UTI with Systemic Symptoms

Use combination therapy: 1

• Amoxicillin plus aminoglycoside, OR
• Second-generation cephalosporin plus aminoglycoside, OR
• Intravenous third-generation cephalosporin

Ciprofloxacin may be used ONLY if: 1

• Local resistance rate is <10%, AND
• Patient does not require hospitalization, AND
• Patient has not used fluoroquinolones in the last 6 months, AND
• Patient has anaphylaxis to β-lactam antimicrobials

Treatment Duration

• 7 to 14 days is generally recommended 1
• 14 days for men when prostatitis cannot be excluded 1
• 7 days may be considered when patient is hemodynamically stable and afebrile for ≥48 hours 1

Essential Management Steps

• Always obtain urine culture and susceptibility testing before initiating therapy 1
• Manage underlying urological abnormality—this is mandatory for cure 1
• Tailor initial empiric therapy based on local resistance patterns and prior culture data 1

UTI in Men

• Treat for 7 to 14 days (limited observational data supports this duration) 2
• Use same first-line agents as for women, but extend duration to 14 days if prostatitis cannot be excluded 1
• Always classify as complicated UTI and obtain urine culture 1

UTI in Women with Diabetes

• Treat similarly to women without diabetes if no voiding abnormalities are present 2
• Use standard first-line agents (nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin) 2
• Consider as complicated UTI if structural abnormalities or immunosuppression coexist 1

Pediatric UTI (Ages 2-24 Months)

Route of Administration

• Oral and parenteral routes are equally efficacious for initial treatment 1
• Use parenteral route if child appears toxic or cannot retain oral intake 1

Empiric Oral Agents

• Amoxicillin-clavulanate 20-40 mg/kg per day in 3 doses 1
• Trimethoprim-sulfamethoxazole (6-12 mg/kg trimethoprim and 30-60 mg/kg sulfamethoxazole per day in 2 doses) 1
• Cephalosporins: cefixime (8 mg/kg per day in 1 dose), cefpodoxime (10 mg/kg per day in 2 doses), or cephalexin (50-100 mg/kg per day in 4 doses) 1

Empiric Parenteral Agents

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

Treatment Duration

• 7 to 14 days total (oral or parenteral, then oral) 1
• Do NOT use nitrofurantoin in febrile infants—it does not achieve adequate parenchymal concentrations for pyelonephritis 1

Recurrent UTI Prevention in Women

Postmenopausal Women

• Vaginal estrogen with or without lactobacillus-containing probiotics as first-line prevention 1
• Methenamine hippurate and/or lactobacillus probiotics as non-antibiotic alternatives 1

Premenopausal Women with Post-Coital Infections

• Low-dose antibiotic within 2 hours of sexual activity for 6-12 months 1
• Preferred agents: nitrofurantoin 50 mg, trimethoprim-sulfamethoxazole 40/200 mg, or trimethoprim 100 mg 1

Premenopausal Women with Non-Coital Infections

• Daily low-dose antibiotic prophylaxis is most effective strategy 1
• Same preferred agents as post-coital prophylaxis 1
• Consider rotating antibiotics at 3-month intervals to avoid resistance 1

Behavioral Modifications

• Control blood glucose in diabetics 1
• Avoid spermicides and harsh vaginal cleansers 1
• Avoid prolonged antibiotic courses (>5 days) and broad-spectrum antibiotics 1

Common Pitfalls to Avoid

• Do NOT use fluoroquinolones as first-line therapy for uncomplicated cystitis—reserve for complicated infections 1, 2
• Do NOT classify recurrent UTI as "complicated" unless structural abnormalities, immunosuppression, or pregnancy exist—this leads to unnecessary broad-spectrum antibiotic use 1
• Do NOT use β-lactam agents empirically for uncomplicated cystitis—they are less effective than first-line options 2
• Do NOT use nitrofurantoin in febrile children or when pyelonephritis is suspected—inadequate tissue penetration 1
• Always check local antibiograms before prescribing trimethoprim-sulfamethoxazole—resistance varies substantially by geography 1