What are the treatment guidelines for urinary tract infections (UTIs)?

Treatment Guidelines for Urinary Tract Infections

First-Line Treatment for Uncomplicated Cystitis in Women

For 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 as first-line therapy. 1

These agents are prioritized because they minimize antimicrobial resistance and "collateral damage" compared to fluoroquinolones and trimethoprim-sulfamethoxazole. 1

Why Not TMP-SMX or Fluoroquinolones First-Line?

• Trimethoprim-sulfamethoxazole is no longer recommended as first-line due to rising E. coli resistance rates, particularly when regional resistance exceeds 20%. 2, 3
• Fluoroquinolones should be reserved for more serious infections like pyelonephritis to preserve their efficacy and minimize selection of multi-resistant pathogens. 1, 4
• Prior antibiotic exposure increases resistance risk—if patients recently received TMP-SMX or fluoroquinolones, avoid these agents. 2

Second-Line Options for Uncomplicated Cystitis

• Cephalosporins (cephalexin, cefixime), trimethoprim, and trimethoprim-sulfamethoxazole can be used as alternatives when first-line agents are contraindicated or unavailable. 1
• Beta-lactams show equivalent symptomatic cure rates to TMP-SMX (RR 0.95% CI 0.81-1.12 short-term; RR 1.06,95% CI 0.93-1.21 long-term). 5

Treatment for Uncomplicated Cystitis in Men

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

• Fluoroquinolones can be used according to local susceptibility patterns. 1
• Men require longer treatment duration (7 days) compared to women due to anatomical differences. 1

Treatment for Uncomplicated Pyelonephritis

For uncomplicated pyelonephritis, high-dose fluoroquinolones remain the recommended first-line oral therapy because E. coli resistance rates to fluoroquinolones remain below 10% in most regions and they demonstrate superior efficacy for upper tract infections. 1, 3

• Ciprofloxacin 500mg every 12 hours for 7-14 days (mild/moderate) or 750mg every 12 hours for 7-14 days (severe/complicated) per FDA labeling. 6
• This recommendation balances efficacy against the need to preserve fluoroquinolones, which is acceptable for pyelonephritis given its greater morbidity risk. 2, 3

Treatment Duration Principles

• Keep antibiotic courses as short as reasonable, generally no longer than 7 days for acute cystitis. 1
• Single-dose fosfomycin, 3-day pivmecillinam, and 5-day nitrofurantoin courses are evidence-based for uncomplicated cystitis. 1
• Shorter courses reduce adverse effects and antimicrobial resistance development. 1

Diagnosis and When to Culture

• Diagnosis of uncomplicated cystitis can be made clinically based on lower urinary tract symptoms and absence of vaginal discharge—urine culture is not routinely needed. 1

Mandatory Urine Culture Situations:

• Suspected acute pyelonephritis 1
• Symptoms not resolving or recurring within 4 weeks after treatment 1
• Atypical symptoms 1
• Pregnancy 1
• Recurrent UTIs (≥3 UTIs/year or 2 UTIs in last 6 months) 1

Post-Treatment Management

• Do not perform routine post-treatment urinalysis or cultures in asymptomatic patients. 1
• If symptoms persist at end of treatment or recur within 2 weeks, obtain urine culture and antimicrobial susceptibility testing. 1

Asymptomatic Bacteriuria

Do not treat asymptomatic bacteriuria in non-pregnant patients. 1, 3

Only Treat ASB In:

• Pregnant women 1, 3
• Prior to mucosal-traumatizing urinary tract procedures 3
• Omit surveillance urine testing in asymptomatic patients with recurrent UTIs. 1

Recurrent UTI Prevention

For patients with recurrent UTIs (≥3/year or 2 in last 6 months): 1

Non-Antimicrobial Strategies (Preferred):

• Increased fluid intake 1
• Vaginal estrogen replacement (postmenopausal women) 1
• Immunoactive prophylaxis 1

Antimicrobial Prophylaxis:

• Consider only after non-antimicrobial interventions fail 1

Symptomatic Therapy Alternative

• For women with mild-to-moderate symptoms, symptomatic therapy without antimicrobials may be considered after shared decision-making with the patient. 1
• This approach further reduces antibiotic exposure and resistance development. 1

Antibiotic Stewardship Principles

The choice of antimicrobial must consider: 1

• Spectrum and susceptibility patterns of pathogens
• Efficacy demonstrated in clinical studies
• Tolerability and adverse reactions
• Collateral damage potential—nitrofurantoin, fosfomycin, and pivmecillinam cause minimal collateral damage compared to fluoroquinolones and third-generation cephalosporins 1, 2

Common Pitfall:

• Avoid reflexively prescribing fluoroquinolones or TMP-SMX for simple cystitis—this drives resistance and should be reserved for appropriate indications. 1, 4