Treatment of Uncomplicated Urinary Tract Infection
For uncomplicated UTI in women, use nitrofurantoin (100 mg twice daily for 5 days), fosfomycin (3 g single dose), or trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) as first-line therapy, with antibiotic selection based on local resistance patterns—specifically, only use trimethoprim-sulfamethoxazole if local resistance is <20%. 1
First-Line Antibiotic Selection
The choice among first-line agents depends critically on your local antibiogram and patient-specific factors:
Nitrofurantoin monohydrate/macrocrystals: 100 mg twice daily for 5 days—this agent has minimal resistance rates and causes the least collateral damage to normal vaginal and fecal flora 2, 1
Fosfomycin trometamol: 3 g as a single dose—offers convenient single-dose administration but has slightly lower efficacy compared to other first-line options 1
Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days—only use if local resistance is documented at <20% or if the specific infecting organism is known to be susceptible 1, 3
Treatment Duration
Treat for as short a duration as reasonable, generally no longer than 7 days for uncomplicated cystitis. 2 The specific durations listed above (3-5 days depending on agent) represent the evidence-based optimal treatment courses. 1
Diagnostic Approach Before Treatment
Obtain urinalysis, urine culture, and sensitivity testing prior to initiating antibiotics in patients with recurrent UTIs (≥3 UTIs per year or ≥2 UTIs in 6 months). 2 For first-time uncomplicated UTI in otherwise healthy women, culture is not routinely required if symptoms are classic (acute-onset dysuria with urgency/frequency). 1
However, obtain urine culture before treatment in:
- Men with UTI symptoms 1
- Older adults ≥65 years 1
- Patients with recurrent infections 1
- Treatment failures 1
- Atypical presentations 1
Second-Line Options
When first-line agents are contraindicated or ineffective, consider:
- Fluoroquinolones (ciprofloxacin, levofloxacin)—reserve as second-line due to increasing resistance and greater collateral damage to normal flora 2, 4
- Beta-lactams (cephalexin, amoxicillin-clavulanate)—also second-line options 5, 4
Critical Antimicrobial Stewardship Principles
Avoid broad-spectrum antibiotics (fluoroquinolones, cephalosporins) as first-line therapy to mitigate the dramatic increase in antimicrobial resistance among uropathogens over the past 20 years. 2 Select agents with the least impact on normal vaginal and fecal flora to reduce collateral damage. 2
Patient-Initiated Treatment Option
For select patients with recurrent UTIs, offer patient-initiated (self-start) treatment while awaiting urine culture results. 2 This approach requires prior patient education and established relationship with reliable patients who can recognize their typical UTI symptoms.
Common Pitfalls to Avoid
Do not routinely use fluoroquinolones as first-line therapy—despite their historical popularity, they should be reserved for pyelonephritis or second-line treatment due to resistance patterns and collateral damage 2, 1
Do not treat asymptomatic bacteriuria except in pregnant women or before invasive urologic procedures—treatment increases antimicrobial resistance without clinical benefit 1
Do not obtain cystoscopy or upper tract imaging routinely in patients presenting with recurrent uncomplicated UTI 2
Verify local resistance patterns—treatment recommendations may not apply in every community due to regional variation in antimicrobial resistance 2