What is the recommended management for urinary tract infections (UTIs) in women?

Management of Urinary Tract Infections in Women

For acute uncomplicated UTI in women, use nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin as first-line therapy for no longer than 7 days, guided by local resistance patterns. 1

Acute Treatment Approach

First-Line Antibiotic Selection

Use these agents based on local antibiogram data: 1

• Nitrofurantoin: 100 mg twice daily for 5 days 1, 2
• Fosfomycin trometamol: 3 g single dose 1, 2
• Trimethoprim-sulfamethoxazole (TMP-SMX): 160/800 mg twice daily for 3 days 1, 2

The choice among these three agents should prioritize local resistance patterns and collateral damage potential, as all three demonstrate similar clinical efficacy but differ in their ecological impact. 1 Nitrofurantoin carries extremely low risk of serious pulmonary (0.001%) or hepatic (0.0003%) toxicity despite historical concerns. 2

Second-Line Alternatives

Reserve these agents for resistance patterns or allergies: 1

• Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) - only if local E. coli resistance <20% 1
• Trimethoprim alone: 200 mg twice daily for 5 days 1
• Fluoroquinolones: Avoid as first-line; reserve for complicated infections 1, 2

Critical Treatment Duration Principle

Treat for the shortest reasonable duration, generally no longer than 7 days. 1 Single-dose antibiotics show increased bacteriological persistence compared to 3-6 day courses (RR 2.01,95% CI 1.05-3.84). 1 Three-day trimethoprim courses are as effective as 5-7 day courses. 3

Diagnostic Requirements

When to Obtain Urine Culture

Obtain urine culture and sensitivity before treatment in these situations: 1

• All recurrent UTI patients with acute episodes 1
• Suspected acute pyelonephritis 1
• Symptoms not resolving or recurring within 4 weeks after treatment 1
• Women with atypical symptoms 1
• Pregnant women 1

For simple first-episode cystitis in non-pregnant women, empiric treatment without culture is acceptable. 1 However, documented cultures during symptomatic periods establish baseline data for future interventions and allow tailoring based on bacterial sensitivities. 1

Self-Start Treatment Option

Consider patient-initiated treatment in reliable patients who can obtain urine specimens before starting therapy and communicate effectively with their provider. 1 This approach requires prior culture data to guide empiric selection while awaiting new culture results. 1

Recurrent UTI Management (≥2 infections in 6 months or ≥3 in 1 year)

Stepwise Prevention Algorithm

Follow this hierarchical approach: 1

Step 1: Behavioral Modifications (All Patients)

• Increase fluid intake to promote frequent urination 1, 2
• Void after sexual intercourse 1, 2
• Avoid spermicides and harsh vaginal cleansers 1
• Control blood glucose in diabetics 1
• Avoid prolonged urine holding 1
• Avoid sequential anal-vaginal intercourse 1, 2

Step 2: Population-Specific Non-Antibiotic Prophylaxis

For postmenopausal women: 1

• Vaginal estrogen (strong recommendation) 1
• Consider adding lactobacillus-containing probiotics 1

For premenopausal women with post-coital infections: 1

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

For all patients desiring non-antibiotic alternatives: 1

• Methenamine hippurate (strong recommendation for women without urinary tract abnormalities) 1, 2
• Immunoactive prophylaxis (strong recommendation for all age groups) 1
• Lactobacillus-containing probiotics (weak recommendation) 1
• Cranberry products with minimum 36 mg/day proanthocyanidin A (weak recommendation, contradictory evidence) 1
• D-mannose (weak recommendation, contradictory evidence) 1

Step 3: Continuous Antibiotic Prophylaxis

When non-antimicrobial measures fail, use daily antibiotic prophylaxis for 6-12 months: 1

• Nitrofurantoin 50 mg daily (preferred - resistance decays quickly) 1
• TMP-SMX 40/200 mg daily 1
• Trimethoprim 100 mg daily 1

Consider rotating antibiotics at 3-month intervals to avoid antimicrobial resistance selection. 1

Critical Pitfalls to Avoid

Asymptomatic Bacteriuria

Never treat asymptomatic bacteriuria in non-pregnant women. 1, 2 This practice fosters antimicrobial resistance and increases recurrent UTI episodes. 1 The only exceptions are pregnant women and patients scheduled for invasive urinary procedures. 1

Do not perform surveillance urine testing in asymptomatic patients with recurrent UTIs. 1

Antibiotic Stewardship Errors

Avoid these common mistakes: 1, 2

• Prolonged courses >5-7 days for uncomplicated UTI 1, 2
• Broad-spectrum antibiotics unnecessarily (disrupts vaginal flora) 1, 2
• Classifying recurrent UTI as "complicated" without true complicating factors (leads to inappropriate broad-spectrum use) 1

Misclassification of Complicated UTI

Reserve "complicated UTI" designation only for: 1

• Congenital urinary tract abnormalities
• Spinal cord injury
• Transplant recipients
• Neurogenic bladder
• Immunosuppression or chemotherapy
• Nephrolithiasis or recent urinary surgery
• Pregnancy

Treatment Failure Management

If symptoms persist despite treatment, repeat urine culture before prescribing additional antibiotics. 1 Assume the organism is not susceptible to the original agent and retreat with a 7-day regimen using a different agent guided by culture results. 1

Special Considerations for Men

Men require 7-day treatment courses (not 3-5 days like women) with TMP-SMX 160/800 mg twice daily or fluoroquinolones based on local susceptibility. 1 Uncomplicated UTI in men is less common and warrants consideration of underlying structural abnormalities.