What is the recommended treatment for urinary tract infections (UTIs)?

Treatment of Urinary Tract Infections

Uncomplicated Cystitis in Women

For uncomplicated cystitis in women, first-line treatment consists of nitrofurantoin 100 mg twice daily for 5 days, fosfomycin trometamol 3 g single dose, or pivmecillinam 400 mg three times daily for 3-5 days. 1

First-Line Agents

• Fosfomycin trometamol 3 g as a single oral dose provides the most convenient regimen with therapeutic urinary concentrations lasting 24-48 hours and minimal disruption to intestinal flora 1, 2
• Nitrofurantoin (macrocrystals or monohydrate) 100 mg twice daily for 5 days offers excellent efficacy with low resistance rates 1
• Pivmecillinam 400 mg three times daily for 3-5 days is recommended where available 1

Alternative Agents (When First-Line Options Unavailable)

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days should only be used if local E. coli resistance rates are below 20% 1, 3
• Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) can be used if local E. coli resistance is below 20% 1
• Fluoroquinolones should be avoided for uncomplicated cystitis and reserved for more serious infections like pyelonephritis due to resistance concerns and adverse effects 1, 4

Treatment Duration and Follow-Up

• Standard 3-5 day courses are adequate for uncomplicated cystitis 1, 5
• Routine post-treatment urine cultures are unnecessary if symptoms resolve 1, 2
• If symptoms persist or recur within 2 weeks, obtain urine culture and antimicrobial susceptibility testing 1

Uncomplicated Cystitis in Men

Men with uncomplicated UTI require longer treatment duration of 7 days with trimethoprim-sulfamethoxazole 160/800 mg twice daily, with fluoroquinolones as an alternative based on local susceptibility patterns. 1

• Men require 7-day treatment courses compared to 3-5 days in women 1
• Fosfomycin is not recommended for routine use in men due to limited efficacy data 2

Uncomplicated Pyelonephritis

For mild-to-moderate uncomplicated pyelonephritis managed outpatient, use ciprofloxacin 500-750 mg twice daily for 7 days or levofloxacin 750 mg daily for 5 days, only if local fluoroquinolone resistance is below 10%. 1

Oral Outpatient Regimens

• Ciprofloxacin 500-750 mg twice daily for 7 days (if resistance <10%) 1
• Levofloxacin 750 mg once daily for 5 days (if resistance <10%) 1
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days can be used as alternative 1
• Cefpodoxime 200 mg twice daily for 10 days or ceftibuten 400 mg daily for 10 days require an initial IV dose of long-acting cephalosporin (e.g., ceftriaxone) 1

Parenteral Regimens for Hospitalized Patients

Patients requiring hospitalization should receive initial IV therapy with fluoroquinolones, extended-spectrum cephalosporins, or aminoglycosides based on local resistance patterns. 1

• Ciprofloxacin 400 mg IV twice daily 1
• Levofloxacin 750 mg IV once daily 1
• Ceftriaxone 1-2 g IV once daily 1
• Cefotaxime 2 g IV three times daily 1
• Gentamicin 5 mg/kg IV once daily or amikacin 15 mg/kg IV once daily 1
• Piperacillin-tazobactam 2.5-4.5 g IV three times daily 1

Critical Considerations

• Fluoroquinolones should only be used when local resistance is below 10% 1
• Carbapenems and novel agents (ceftolozane-tazobactam, ceftazidime-avibactam) should be reserved for multidrug-resistant organisms confirmed by early culture results 1
• Oral fosfomycin is not recommended for pyelonephritis due to insufficient efficacy data 2

Complicated Urinary Tract Infections

Complicated UTIs require individualized antimicrobial selection based on urine culture results, local resistance patterns, and correction of underlying urological abnormalities. 1

Key Principles

• Always obtain urine culture and antimicrobial susceptibility testing before initiating therapy 1
• The microbial spectrum is broader than uncomplicated UTIs, including E. coli, Proteus, Klebsiella, Pseudomonas, Serratia, and Enterococcus species 1
• Antimicrobial resistance is more likely, including ESBL-producing organisms and multidrug-resistant pathogens 1, 6
• Address underlying urological abnormalities (obstruction, foreign bodies, incomplete voiding) as definitive management 1

Empiric Therapy Options

• For ESBL-producing E. coli: nitrofurantoin, fosfomycin, pivmecillinam, or carbapenems for severe infections 6
• For carbapenem-resistant organisms: ceftazidime-avibactam, meropenem-vaborbactam, or cefiderocol 6
• Treatment duration typically 7-14 days depending on severity and response 1

Recurrent Urinary Tract Infections

For recurrent UTIs (≥3 episodes per year or 2 in 6 months), prioritize non-antimicrobial preventive measures first, including vaginal estrogen in postmenopausal women and immunoactive prophylaxis, before resorting to antimicrobial prophylaxis. 1

Non-Antimicrobial Prevention (First-Line)

• Vaginal estrogen in postmenopausal women (strong recommendation) 1
• Immunoactive prophylaxis for all age groups (strong recommendation) 1
• Increased fluid intake in premenopausal women 1
• Methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 1
• Probiotics containing strains with proven efficacy for vaginal flora regeneration 1
• Cranberry products may reduce episodes but evidence quality is low 1
• D-mannose has weak and contradictory evidence 1

Antimicrobial Prophylaxis (When Non-Antimicrobial Measures Fail)

• Use continuous or postcoital antimicrobial prophylaxis only after non-antimicrobial interventions have failed 1
• Self-administered short-term therapy at symptom onset for patients with good compliance 1
• Counsel patients regarding potential side effects and resistance development 1

Special Populations

Pregnant Women

• Treat asymptomatic bacteriuria with standard short-course therapy or single-dose fosfomycin 2
• For pyelonephritis in pregnancy, hospitalization with IV antibiotics is indicated 7
• Avoid trimethoprim in first trimester and trimethoprim-sulfamethoxazole in last trimester 1

Patients with Diabetes

• Women with diabetes without voiding abnormalities should be treated similarly to women without diabetes for acute cystitis 5

Common Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria except in pregnant women or before urological procedures breaching the mucosa 2
• Avoid fluoroquinolones for uncomplicated cystitis due to resistance concerns and serious adverse effects including tendon, muscle, joint, nerve, and CNS complications 1, 4
• Do not use amoxicillin alone for empiric treatment due to high resistance rates (median 75% of E. coli isolates) 1
• Verify local resistance patterns before using trimethoprim-sulfamethoxazole; it should not be used if local resistance exceeds 20% 1
• Do not use fosfomycin for pyelonephritis or in men due to insufficient efficacy data 2
• Avoid β-lactam agents (amoxicillin-clavulanate, cefpodoxime) as first-line empiric therapy for uncomplicated cystitis as they are less effective 5