What are the latest clinical practice guidelines for treating urinary tract infections (UTIs)?

Latest Clinical Practice Guidelines for Urinary Tract Infections

Uncomplicated Cystitis in Women

For first-line treatment of uncomplicated cystitis in women, use fosfomycin trometamol 3g single dose, nitrofurantoin 100mg twice daily for 5 days, or pivmecillinam 400mg three times daily for 3-5 days. 1

• These agents are preferred based on efficacy, tolerability, and favorable resistance patterns in most communities 1
• Fosfomycin is FDA-approved specifically for uncomplicated cystitis in women caused by E. coli and Enterococcus faecalis 2
• Nitrofurantoin formulations include macrocrystals 50-100mg four times daily or monohydrate/macrocrystals 100mg twice daily, both for 5 days 1

Alternative Agents

When first-line options are unavailable or contraindicated:

• Cephalosporins (e.g., cefadroxil 500mg twice daily for 3 days) if local E. coli resistance is <20% 1
• Trimethoprim 200mg twice daily for 5 days (avoid in first trimester of pregnancy) 1
• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days (avoid in last trimester of pregnancy) 1

Important caveat: Fluoroquinolones and trimethoprim-sulfamethoxazole should be avoided for empiric treatment due to high resistance rates in many communities, particularly in patients recently exposed to these agents or at risk for ESBL-producing organisms 3, 4

Symptomatic Treatment Option

• For women with mild-to-moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to antimicrobials after shared decision-making 1
• This approach reduces antimicrobial exposure but requires patient understanding of when to seek further care

Uncomplicated Cystitis in Men

For men with uncomplicated UTI, use trimethoprim-sulfamethoxazole 160/800mg twice daily for 7 days. 1

• Fluoroquinolones can be prescribed according to local susceptibility patterns 1
• Men require longer treatment duration (7 days minimum) compared to women due to potential prostatic involvement 1

Follow-Up and Treatment Failure

Do not perform routine post-treatment urinalysis or urine cultures in asymptomatic patients. 1

For treatment failure or early recurrence:

• If symptoms persist at end of treatment or recur within 2 weeks, obtain urine culture with antimicrobial susceptibility testing 1
• Assume the organism is resistant to the initial agent and retreat with a different antimicrobial for 7 days 1
• If symptoms recur within 4 weeks after treatment completion, obtain urine culture before retreating 1

Recurrent UTIs (≥3 UTIs/year or ≥2 UTIs in 6 months)

Diagnose recurrent UTI via urine culture, not clinical symptoms alone. 1

Non-Antimicrobial Prevention Strategies (Preferred First)

• Vaginal estrogen replacement in postmenopausal women (strong recommendation) 1
• Immunoactive prophylaxis for all age groups (strong recommendation) 1
• Methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 1
• Increased fluid intake in premenopausal women (weak recommendation) 1
• Probiotics containing strains with proven efficacy for vaginal flora regeneration (weak recommendation) 1
• Cranberry products (weak recommendation with contradictory evidence) 1
• D-mannose (weak recommendation with contradictory evidence) 1

Antimicrobial Prophylaxis

When non-antimicrobial interventions fail, use continuous or postcoital antimicrobial prophylaxis. 1

• Counsel patients regarding potential side effects and resistance development 1
• Self-administered short-term antimicrobial therapy is appropriate for patients with good compliance (strong recommendation) 1

Diagnostic Workup

• Do not perform extensive routine workup (cystoscopy, full abdominal ultrasound) in women younger than 40 years with recurrent UTI and no risk factors 1

Acute Pyelonephritis

Oral Treatment Options

• Ciprofloxacin 500-750mg twice daily for 7 days 5
• Levofloxacin 750mg once daily for 5 days 5
• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 14 days 5

Parenteral Treatment

• Initial IV therapy with fluoroquinolones, aminoglycosides, extended-spectrum cephalosporins, or penicillins 5
• Switch to oral therapy once clinical improvement occurs (typically 24-48 hours) 5

Febrile UTIs in Infants and Children (2-24 months)

Treat febrile infants with UTIs for 7-14 days total, using either oral or parenteral route initially based on clinical severity. 1

Parenteral Options (for toxic-appearing or unable to retain oral intake)

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

Oral Options (once able to retain oral intake)

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

Critical caveat: Do not use nitrofurantoin in febrile infants, as it does not achieve adequate serum/parenchymal concentrations to treat pyelonephritis or urosepsis 1

Imaging

• Perform renal and bladder ultrasonography (RBUS) in all febrile infants with UTIs to detect anatomic abnormalities 1

Special Populations

Pregnant Women

• Always obtain urine culture before treatment 1
• Avoid trimethoprim in first trimester and trimethoprim-sulfamethoxazole in last trimester 1
• Nitrofurantoin and beta-lactams are generally safe options 1

Asymptomatic Bacteriuria

• Do not treat asymptomatic bacteriuria except in pregnant women or prior to urinary tract procedures 5
• Treatment of asymptomatic bacteriuria may be harmful in other populations 1

Key Principles for Antimicrobial Selection

The 2024 European Association of Urology guidelines emphasize that antimicrobial choice should be guided by:

• Spectrum and susceptibility patterns of aetiological pathogens 1
• Efficacy for the particular indication in clinical studies 1
• Tolerability and adverse reactions 1
• Adverse ecological effects (collateral damage from resistance selection) 1
• Costs and availability 1

Know your local resistance patterns for E. coli to trimethoprim-sulfamethoxazole and cephalexin, as there is substantial geographic variability 1