What is the treatment for Escherichia coli (E. coli) urinary tract infection (UTI)?

From the Guidelines

For the treatment of uncomplicated E. coli urinary tract infections (UTIs), clinicians should prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim–sulfamethoxazole (TMP–SMZ) for 3 days, or fosfomycin as a single dose. When considering the treatment of E. coli UTIs, it's essential to differentiate between uncomplicated cystitis and pyelonephritis, as well as complicated UTIs, which may require different treatment approaches 1. For women with uncomplicated bacterial cystitis, the recommended treatment options include nitrofurantoin for 5 days, TMP–SMZ for 3 days, or fosfomycin as a single dose, as these regimens have been shown to be effective against E. coli, which accounts for more than 75% of all bacterial cystitis 1. In cases of uncomplicated pyelonephritis, treatment options include fluoroquinolones for 5 to 7 days or TMP–SMZ for 14 days, based on antibiotic susceptibility 1. Key considerations in the treatment of E. coli UTIs include:

• The use of short-course antibiotics to minimize the risk of adverse effects and promote antibiotic stewardship
• The selection of antibiotics that target E. coli, given its high prevalence in UTIs
• The differentiation between uncomplicated and complicated UTIs, as well as between cystitis and pyelonephritis, to guide treatment decisions
• The importance of monitoring for symptoms of worsening infection or treatment failure, which may indicate the need for alternative treatment approaches 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to empiric selection of therapy Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris Complicated Urinary Tract Infection and Pyelonephritis Ciprofloxacin is indicated for the treatment of complicated urinary tract infections and pyelonephritis due to Escherichia coli

E-coli UTI treatment can be done using:

• Trimethoprim-sulfamethoxazole for uncomplicated urinary tract infections
• Ciprofloxacin for complicated urinary tract infections and pyelonephritis 2 3

From the Research

E-coli UTI Treatment Options

• The recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females is a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 4.
• High rates of resistance for trimethoprim-sulfamethoxazole and ciprofloxacin preclude their use as empiric treatment of UTIs in several communities, particularly if patients who were recently exposed to them or in patients who are at risk of infections with extended-spectrum β-lactamases (ESBLs)-producing Enterobacteriales 4.
• Second-line options include oral cephalosporins such as cephalexin or cefixime, fluoroquinolones and β-lactams, such as amoxicillin-clavulanate 4.

Treatment of ESBL-Producing E-coli

• Oral treatment options for UTIs due to ESBLs-E coli include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 4, 5.
• More than 95% of all ESBL producing Enterobacteriacae were sensitive to pivmecillinam, fosfomycin and nitrofurantoin 5.

Resistance to Common Antibiotics

• The prevalence of MDR E. coli increased from 28.4% in 2005 to 34.3% in 2011-12, while the prevalence of nitrofurantoin non-susceptibility decreased from 23.2% to 10.7% during the same period 6.
• Nitrofurantoin retains antimicrobial activity against multidrug-resistant urinary Escherichia coli from US outpatients, with resistance observed in only 2.1%, 7.5%, and 24.1% of isolates resistant to three, four, or five antimicrobial agents, respectively 7.

Risk Factors for Resistance

• Recurrent UTI, genitourinary abnormalities, and previous use of trimethoprim-sulfamethoxazole within 90 days are risk factors for trimethoprim-sulfamethoxazole resistance in E. coli 8.