Treatment of Urinary Tract Infection (UTI)
For uncomplicated cystitis in women, use first-line antibiotics: fosfomycin 3g single dose, nitrofurantoin 100mg twice daily for 5 days, or trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days (only if local resistance is <20%). 1
Uncomplicated Cystitis in Women
First-Line Treatment Options
The European Association of Urology 2024 guidelines provide the most current evidence-based approach 1:
- Fosfomycin trometamol: 3g single dose (1 day treatment) 1
- Nitrofurantoin: 100mg twice daily for 5 days (macrocrystals or monohydrate formulations) 1
- Pivmecillinam: 400mg three times daily for 3-5 days 1
Alternative Agents
When first-line options are contraindicated or unavailable 1:
- Cephalosporins (e.g., cefadroxil 500mg twice daily for 3 days) - only 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, 2
Treatment Duration
Keep antibiotic courses as short as reasonable, generally no longer than 7 days. 1 The 3-5 day regimens for uncomplicated cystitis achieve excellent cure rates while minimizing antibiotic resistance and adverse effects 1.
Key Diagnostic Considerations
- Obtain urine culture before treatment in recurrent UTI patients to guide therapy 1
- For simple first episodes with classic symptoms (dysuria, frequency, urgency), urinalysis alone may suffice without culture 1
- Do not treat asymptomatic bacteriuria except in pregnant women or before urologic procedures 1
Uncomplicated Cystitis in Men
Men require longer treatment duration 1:
- Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1
- Fluoroquinolones may be used according to local susceptibility patterns 1
The 7-day duration accounts for potential subclinical prostatic involvement 1.
Uncomplicated Pyelonephritis
For upper tract infections with fever, flank pain, and systemic symptoms 1:
Oral Outpatient Treatment (Mild-Moderate Cases)
- Ciprofloxacin: 500-750mg twice daily for 7 days (only if local resistance <10%) 1
- Levofloxacin: 750mg once daily for 5 days 1
- Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 14 days 1
- Cefpodoxime: 200mg twice daily for 10 days 1
- Ceftibuten: 400mg once daily for 10 days 1
Consider initial IV dose of long-acting cephalosporin (e.g., ceftriaxone) before switching to oral therapy to ensure adequate initial coverage 1.
Imaging Requirements
- Perform ultrasound to rule out obstruction in patients with history of stones, renal dysfunction, or high urine pH 1
- If fever persists >72 hours or clinical deterioration occurs, obtain CT scan immediately 1
Complicated UTI
Complicated UTIs require combination IV therapy initially, then tailored oral therapy based on culture results for 7-14 days. 1
Defining Features of Complicated UTI 1
Complicated UTIs occur with:
- Urinary tract obstruction at any level 1
- Foreign bodies (catheters, stents) 1
- Male sex 1
- Pregnancy 1
- Diabetes mellitus 1
- Immunosuppression 1
- Recent instrumentation 1
- Multidrug-resistant organisms 1
Empiric Treatment for Complicated UTI 1
Use combination IV therapy 1:
- Amoxicillin PLUS aminoglycoside, OR 1
- Second-generation cephalosporin PLUS aminoglycoside, OR 1
- Third-generation cephalosporin IV 1
Do not use fluoroquinolones empirically if the patient is from a urology department or has used fluoroquinolones in the last 6 months due to high resistance rates 1.
Treatment Duration
- 7-14 days total depending on clinical response and underlying abnormality 1
- 14 days for men when prostatitis cannot be excluded 1
- May shorten to 7 days if patient is hemodynamically stable and afebrile for ≥48 hours 1
Mandatory: Address the underlying urological abnormality (remove catheter, relieve obstruction, drain abscess) as antimicrobial therapy alone will fail without correcting predisposing factors 1.
Recurrent UTI Management
For women with ≥3 UTIs per year or ≥2 in 6 months, implement non-antibiotic preventive measures first before considering antibiotic prophylaxis. 1
Non-Antimicrobial Prevention (Try First) 1
- Vaginal estrogen in postmenopausal women (strong recommendation) 1
- Increased fluid intake 1
- Immunoactive prophylaxis (strong recommendation) 1
- Post-coital voiding 1
- Avoid spermicide-containing contraceptives 1
- Methenamine hippurate for women without urinary tract abnormalities 1
Weaker Evidence Options
Patients may try these, but should understand the evidence is limited 1:
- Cranberry products (contradictory evidence) 1
- D-mannose (weak evidence) 1
- Probiotics with proven vaginal flora strains 1
Antibiotic Prophylaxis (When Non-Antimicrobial Fails)
Use continuous or post-coital prophylaxis only after non-antimicrobial interventions fail 1:
- Low-dose daily or post-coital antibiotics 1
- Self-start therapy for compliant patients who can recognize symptoms early 1
Diagnostic Workup for Recurrent UTI
- Obtain urine culture with each symptomatic episode before treatment 1
- Do not perform routine cystoscopy or imaging in women <40 years without risk factors 1
- Consider imaging only if: gross hematuria persists after treatment, repeated pyelonephritis, stone-forming organisms, or symptoms suggest fistula 1
Critical Pitfalls to Avoid
Never treat asymptomatic bacteriuria (except in pregnancy or before urologic procedures) - this drives resistance without benefit 1
Do not perform post-treatment cultures in asymptomatic patients - symptom resolution is sufficient 1
Avoid fluoroquinolones for simple cystitis - reserve for pyelonephritis or complicated infections to minimize collateral damage and resistance 1
Do not use trimethoprim-sulfamethoxazole empirically if local E. coli resistance exceeds 20% 1
Always obtain culture before treating complicated UTI - empiric therapy must be tailored based on susceptibility results 1
Rule out obstruction immediately in pyelonephritis patients with stones, renal dysfunction, or persistent fever >72 hours 1