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

Guidelines for Urinary Tract Infection Treatment

Uncomplicated Cystitis in Women

First-line treatment for uncomplicated cystitis should be fosfomycin trometamol 3g single dose, nitrofurantoin 100mg twice daily for 5 days, or pivmecillinam 400mg three times daily for 3-5 days. 1

• These agents are preferred over trimethoprim-sulfamethoxazole and fluoroquinolones due to rising resistance rates and concerns about collateral damage (selection of multi-resistant pathogens) 2, 1
• Fluoroquinolones should be reserved for more invasive infections and avoided as first-line empirical therapy for uncomplicated cystitis 1
• Trimethoprim-sulfamethoxazole is no longer recommended as first-line therapy due to increasing resistance among community-acquired E. coli 3

Diagnostic approach:

• Urine culture is recommended for women with atypical symptoms, symptoms that don't resolve or recur within 4 weeks after treatment, pregnant women, and all cases of recurrent UTI 1
• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1

Uncomplicated Pyelonephritis

For oral treatment of uncomplicated pyelonephritis, use ciprofloxacin 500-750mg twice daily for 7 days or levofloxacin 750mg once daily for 5 days. 1

• Alternative oral option: trimethoprim-sulfamethoxazole 160/800mg twice daily for 14 days 1
• For parenteral treatment, initiate IV therapy with fluoroquinolones, aminoglycosides, extended-spectrum cephalosporins, or penicillins 1
• Perform urinalysis including white and red blood cells and nitrite assessment, plus urine culture with antimicrobial susceptibility testing in all cases 2
• Evaluate upper urinary tract via ultrasound in patients with history of urolithiasis, renal function disturbances, or high urine pH 2
• Consider contrast-enhanced CT or excretory urography if patient remains febrile after 72 hours of treatment or if clinical status deteriorates 2

UTIs in Men

For UTIs in men, use trimethoprim-sulfamethoxazole 160/800mg twice daily for 7 days, or fluoroquinolones according to local susceptibility testing. 1

• Treatment duration should be 7-14 days, with 14 days recommended when prostatitis cannot be excluded 2

Complicated UTIs

For complicated UTIs with systemic symptoms, use combination therapy with amoxicillin plus an aminoglycoside, a second-generation cephalosporin plus an aminoglycoside, or an IV third-generation cephalosporin. 2

• Only use ciprofloxacin if local resistance rate is <10% and when: the entire treatment is given orally, the patient doesn't require hospitalization, or the patient has anaphylaxis to β-lactam antimicrobials 2
• Do not use ciprofloxacin or other fluoroquinolones for empirical treatment in patients from urology departments or when patients have used fluoroquinolones in the last 6 months 2
• Treatment duration is 7-14 days (14 days for men when prostatitis cannot be excluded) 2, 1
• Management of any underlying urological abnormality or complicating factors is mandatory 2, 1

Recurrent UTIs

Recurrent UTI is defined as at least three UTIs per year or two UTIs in the last 6 months. 1

Non-antimicrobial prevention strategies (attempt in this order):

• Diagnose recurrent UTI via urine culture 2
• Increase fluid intake in premenopausal women 2, 1
• Use vaginal estrogen replacement in postmenopausal women (strong recommendation) 2, 1
• Use immunoactive prophylaxis to reduce recurrent UTI in all age groups 2, 1
• Consider probiotics containing strains of proven efficacy for vaginal flora regeneration 2
• Advise on cranberry products, though evidence quality is low with contradictory findings 2
• Consider D-mannose, though evidence is weak and contradictory 2
• Use methenamine hippurate in women without urinary tract abnormalities (strong recommendation) 2, 1
• Consider endovesical instillations of hyaluronic acid or hyaluronic acid/chondroitin sulfate combination when less invasive approaches fail 2

Antimicrobial prophylaxis strategies (when non-antimicrobial interventions fail):

• Use continuous or postcoital antimicrobial prophylaxis 2, 1
• For patients with good compliance, consider self-administered short-term antimicrobial therapy 2, 1

Diagnostic workup:

• Do not perform extensive routine workup (cystoscopy, full abdominal ultrasound) in women younger than 40 years with recurrent UTI and no risk factors 2

Catheter-Associated UTIs

Catheter-associated UTI refers to UTI occurring in an individual whose urinary tract is currently catheterized or has been catheterized within the past 48 hours. 2

• Catheterization duration is the most important risk factor for CA-UTI development 2
• Signs include new onset or worsening of fever, rigor, altered mental status, malaise, lethargy with no other identified cause, flank pain, costovertebral angle tenderness, acute hematuria, pelvic discomfort, dysuria, urgent or frequent urination, and suprapubic pain or tenderness 2
• CA-UTIs are the leading cause of secondary health care-associated bacteremia with approximately 10% mortality 2

Special Considerations

Asymptomatic bacteriuria should not be treated except in pregnant women or prior to urinary tract procedures. 1

• Surveillance urine testing should be omitted in asymptomatic patients with history of recurrent UTIs 1
• For women whose symptoms don't resolve by end of treatment or recur within 2 weeks, perform urine culture and antimicrobial susceptibility testing 1
• For retreatment, assume the infecting organism is not susceptible to the original agent and use a 7-day regimen with another agent 1

Urosepsis Recognition

Urosepsis is defined as life-threatening organ dysfunction from dysregulated host response to infection, indicated by an increase in SOFA score of 2 points. 2

• Quick SOFA (qSOFA) criteria for rapid identification: respiratory rate ≥22 breaths/min, altered mental status, or systolic blood pressure ≤100 mmHg 2
• Prompt differentiation between uncomplicated and potentially obstructive pyelonephritis is crucial, as the latter can swiftly progress to urosepsis 2