What is the recommended treatment for a patient with a urinary tract infection (UTI)?

Treatment of Urinary Tract Infection (UTI)

For uncomplicated UTIs in women, use first-line antibiotics: nitrofurantoin (5 days), trimethoprim-sulfamethoxazole (3 days), or fosfomycin (single dose), with treatment duration generally no longer than 7 days. 1

Diagnostic Approach

When to Obtain Urine Culture

• Obtain urinalysis and urine culture with sensitivity testing before initiating treatment in patients with recurrent UTIs, treatment failure, atypical symptoms, suspected pyelonephritis, or pregnancy 1
• For simple uncomplicated cystitis in women with typical symptoms (dysuria, frequency, urgency, suprapubic pain) and no vaginal discharge, clinical diagnosis alone is sufficient without culture 1, 2
• Do not perform surveillance urine testing in asymptomatic patients 1

Critical Distinction: Symptomatic vs Asymptomatic

• Never treat asymptomatic bacteriuria except in pregnant women or patients scheduled for invasive urinary procedures 1
• This is a strong recommendation that prevents unnecessary antibiotic exposure and resistance development 1

First-Line Antibiotic Treatment

For Uncomplicated Cystitis in Women

The choice should be guided by local antibiogram patterns, but the following are recommended first-line agents 1:

• Nitrofurantoin: 100 mg twice daily for 5 days 1
• Trimethoprim-sulfamethoxazole (TMP-SMX): 160/800 mg twice daily for 3 days 1
• Fosfomycin trometamol: 3 g single dose 1
• Trimethoprim alone: 200 mg twice daily for 5 days (for sulfa allergies) 1

These agents are preferred because they effectively treat UTIs while causing less collateral damage to normal flora compared to fluoroquinolones and cephalosporins 1

For UTIs in Men

• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 7 days 1
• Fluoroquinolones may be prescribed based on local susceptibility patterns 1
• Always obtain urine culture in men, as UTIs are considered complicated in this population 1

Treatment Duration Principles

• Use the shortest reasonable duration, generally no longer than 7 days for acute cystitis 1
• Single-dose therapy has higher bacteriological persistence rates and is not recommended as standard practice 1
• Three-day regimens are preferred for simple cystitis when using TMP-SMX 1, 3

Second-Line Alternatives

When first-line agents cannot be used due to resistance patterns (>20% local E. coli resistance) or allergies 1:

• Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) 1
• Fluoroquinolones should be reserved as second-line agents due to resistance concerns and collateral damage 1

Complicated UTIs and Pyelonephritis

Uncomplicated Pyelonephritis (Outpatient)

• Fluoroquinolones are first-line for oral therapy 1:
  • Ciprofloxacin 500-750 mg twice daily for 7 days 1
  • Levofloxacin 750 mg daily for 5 days 1
• Alternative: TMP-SMX 160/800 mg twice daily for 14 days (if susceptible) 1

Hospitalized Pyelonephritis

Initial intravenous therapy 1:

• Ciprofloxacin 400 mg twice daily 1
• Levofloxacin 750 mg daily 1
• Ceftriaxone 1-2 g daily 1
• Gentamicin 5 mg/kg daily 1
• Reserve carbapenems only for multidrug-resistant organisms with early culture confirmation 1

Complicated UTIs with Resistant Organisms

• Use culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than 7 days 1
• Address underlying urological abnormalities or complicating factors 1

Special Considerations

Patient-Initiated Treatment

• May offer self-start treatment to select recurrent UTI patients while awaiting culture results 1
• This requires prior documentation of positive cultures with symptomatic episodes 1

Antimicrobial Stewardship

• Critical pitfall: Avoid fluoroquinolones and cephalosporins as first-line agents to minimize resistance development and collateral damage to normal flora 1
• Local resistance patterns should guide empiric therapy selection 1
• The three first-line agents (nitrofurantoin, TMP-SMX, fosfomycin) have similar efficacy but lower ecological impact 1

Treatment Failure

• If symptoms persist or recur within 2 weeks, obtain urine culture and susceptibility testing 1
• Assume the organism is not susceptible to the original agent 1
• Retreat with a 7-day regimen using a different agent 1

Recurrent UTIs (≥3 UTIs/year or 2 in 6 months)

• Document each episode with culture before treatment 1
• Consider antibiotic prophylaxis after discussing risks, benefits, and alternatives 1
• Non-antibiotic alternatives include vaginal estrogen (postmenopausal women), increased fluid intake, and immunoactive prophylaxis 1

Common Pitfalls to Avoid

• Do not routinely perform cystoscopy or imaging in women with recurrent UTI unless there are risk factors or atypical features 1
• Do not use single-dose therapy as standard practice due to higher failure rates 1
• Do not treat asymptomatic bacteriuria in non-pregnant, non-surgical patients 1
• Do not prescribe fluoroquinolones as first-line unless resistance patterns or allergies necessitate their use 1