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

Treatment of Urinary Tract Infection Symptoms

For uncomplicated UTI symptoms in women, initiate nitrofurantoin 5 days, trimethoprim-sulfamethoxazole 3 days (if local resistance <20%), or fosfomycin single dose as first-line therapy, with treatment duration generally no longer than 7 days. 1, 2, 3

Diagnostic Approach

Obtain Urine Culture Before Treatment

• Obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with recurrent UTIs. 1
• In women with typical symptoms (dysuria, frequency, urgency, suprapubic pain) without vaginal discharge, self-diagnosis is accurate enough to proceed with empiric treatment without further testing if this is a first or infrequent episode. 3, 4
• Reserve urine culture for women with recurrent infection, treatment failure, history of resistant organisms, or atypical presentation. 3
• Dysuria is the most diagnostic symptom, with >90% accuracy for UTI in young women when vaginal irritation or discharge is absent. 1

When Culture Results Are Pending

• Patient-initiated treatment (self-start therapy) may be offered to select patients with recurrent UTIs while awaiting culture results. 1
• Use prior culture data if available to guide empiric antibiotic selection. 1

First-Line Antibiotic Treatment

Recommended Agents (in order of preference)

Use first-line therapy dependent on local antibiogram: 1

• Nitrofurantoin for 5 days - preferred due to low resistance rates and minimal collateral damage 1, 2, 3
• Trimethoprim-sulfamethoxazole for 3 days - only if local resistance <20% 1, 3
• Fosfomycin single 3-gram dose 1, 3

Treatment Duration

• Treat acute cystitis episodes with as short a duration as reasonable, generally no longer than 7 days. 1
• Three-day therapy is optimal for most uncomplicated UTIs, balancing efficacy with minimizing resistance development. 3

Special Populations

Men with UTI Symptoms

• Always obtain urine culture and susceptibility testing before initiating therapy. 5
• Treat for 14 days when prostatitis cannot be excluded. 5
• First-line options include trimethoprim, trimethoprim-sulfamethoxazole, or nitrofurantoin for 7 days minimum. 5, 3
• Consider evaluation for underlying urological abnormalities or complicating factors. 5

Postmenopausal Women with Recurrent UTIs

• Consider vaginal estrogen with or without lactobacillus-containing probiotics as preventive therapy. 1
• This approach addresses the underlying risk factor of vaginal atrophy. 1

Premenopausal Women with Post-Coital Infections

• Consider low-dose antibiotic within 2 hours of sexual activity for 6-12 months. 1

Second-Line Options

When First-Line Agents Are Inappropriate

• Fluoroquinolones should be avoided if patient used them in last 6 months or local resistance >10%. 2, 5
• Beta-lactams (amoxicillin-clavulanate) can be used but have higher rates of collateral damage. 1, 6
• For culture-resistant organisms requiring parenteral therapy, use culture-directed antibiotics for no longer than 7 days. 1

Critical Pitfalls to Avoid

Do NOT Treat Asymptomatic Bacteriuria

• Strongly avoid treating asymptomatic bacteriuria in non-pregnant patients. 1
• Treatment of asymptomatic bacteriuria fosters antimicrobial resistance and increases recurrent UTI episodes. 1
• Omit surveillance urine testing in asymptomatic patients with recurrent UTIs. 1

Antimicrobial Stewardship Principles

• Combine knowledge of local antibiogram with selection of agents having least impact on normal vaginal and fecal flora. 1
• Avoid classifying patients with recurrent UTIs as "complicated" unless they have structural/functional abnormalities, as this leads to unnecessary broad-spectrum antibiotic use. 1
• Consider antibiotic resistance patterns in both the individual patient and community. 1, 2

When Symptoms Persist

• If symptoms persist despite treatment, repeat urine culture to assess for ongoing bacteriuria before prescribing additional antibiotics. 1
• Consider alternative diagnoses including vaginitis, vulvar lesions, physical/chemical irritants, or sexually transmitted diseases. 7

Imaging and Cystoscopy

• Cystoscopy and upper tract imaging should NOT be routinely obtained in otherwise healthy women presenting with recurrent UTI. 1
• Reserve these studies for patients with complicating factors such as structural abnormalities, hematuria without infection, or treatment failure. 1