Treatment of Uncomplicated UTI in Females
For uncomplicated cystitis in women, first-line treatment consists of nitrofurantoin 100 mg twice daily for 5 days, fosfomycin 3 g single dose, or trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (only if local resistance <20%). 1, 2
Diagnosis and When to Treat
- Diagnosis can be made clinically based on typical lower urinary tract symptoms (dysuria, frequency, urgency) without vaginal discharge in women with uncomplicated UTI 1
- Urine culture is NOT routinely needed for typical presentations 1, 3
- Obtain urine culture in these specific situations: suspected pyelonephritis, symptoms not resolving or recurring within 4 weeks, atypical symptoms, pregnant women, or history of resistant organisms 1, 3
Alternative to Antibiotics
- For mild to moderate symptoms, symptomatic therapy with ibuprofen alone may be considered as an alternative to antimicrobials after shared decision-making with the patient 1, 3
First-Line Antibiotic Options
Nitrofurantoin (Preferred by Many Guidelines)
- Dose: 100 mg twice daily for 5 days 1, 2
- Minimal resistance rates and low collateral damage to gut flora 2, 4
- Effective against most E. coli strains causing uncomplicated UTI 4, 3
Fosfomycin Trometamol
- Dose: 3 g single dose 1, 5
- Convenient single-dose regimen with good patient compliance 2, 6
- FDA-approved specifically for uncomplicated cystitis in women caused by E. coli and Enterococcus faecalis 5
- Must be mixed with water before ingesting; never take in dry form 5
- Slightly lower efficacy than nitrofurantoin but comparable overall cure rates 2, 6
Trimethoprim-Sulfamethoxazole (TMP-SMX)
- Dose: 160/800 mg twice daily for 3 days 1, 2
- Only use if local E. coli resistance rates are <20% or if susceptibility is confirmed 1, 2
- High resistance rates in many communities now preclude empiric use 4, 7
Pivmecillinam (Where Available)
Alternative Second-Line Options
When first-line agents are contraindicated or unavailable:
- Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) - only if local E. coli resistance <20% 1
- Trimethoprim alone: 200 mg twice daily for 5 days (not in first trimester of pregnancy) 1
What NOT to Use
- Fluoroquinolones should NOT be used for uncomplicated UTI due to high rates of adverse effects, antimicrobial resistance concerns, and FDA black box warnings 4, 7
- Despite this, fluoroquinolones remain overprescribed (36.4% of prescriptions in recent data), representing guideline-discordant care 7
Treatment Duration Considerations
- 3-day therapy achieves similar symptomatic cure as 5-10 day therapy but has slightly lower bacteriological cure rates 8
- 5-day courses are preferred for nitrofurantoin to optimize bacteriological eradication 1, 2
- Shorter courses have fewer adverse effects (17% reduction in adverse events compared to longer courses) 8
Post-Treatment Management
- Routine post-treatment urine culture is NOT indicated for asymptomatic patients 1
- Obtain culture and susceptibility testing if symptoms persist at end of treatment or recur within 2 weeks 1
- For treatment failure, assume resistance to initial agent and retreat with a different antibiotic for 7 days 1
Common Pitfalls to Avoid
- Do not treat asymptomatic bacteriuria except in pregnant women or before invasive urologic procedures 1, 2
- Do not use fosfomycin for pyelonephritis or perinephric abscess - it is only indicated for uncomplicated cystitis 5
- Avoid empiric TMP-SMX without knowing local resistance patterns - many areas now have >20% resistance 4, 7
- In elderly women, genitourinary symptoms may not indicate cystitis - consider alternative diagnoses 1