Treatment for Uncomplicated Urinary Tract Infection
For uncomplicated UTIs in women, first-line treatment is 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 is <20%). 1, 2
First-Line Antibiotic Options for Women
The 2024 European Association of Urology guidelines establish clear first-line agents 1:
- Nitrofurantoin: 100 mg twice daily for 5 days—this is the most consistently recommended option with minimal resistance and low collateral damage 1, 2, 3
- Fosfomycin trometamol: 3 g single dose—convenient single-dose regimen, though slightly lower efficacy than nitrofurantoin 1, 2, 3
- Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days—effective but only use if local E. coli resistance is <20% or if susceptibility is confirmed 1, 2, 4, 3
- Pivmecillinam: 400 mg three times daily for 3-5 days (where available) 1
Alternative Agents
If first-line options are contraindicated or unavailable 1:
- Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days)—only if local E. coli resistance is <20% 1
- Trimethoprim alone: 200 mg twice daily for 5 days—avoid in first trimester of pregnancy 1
Fluoroquinolones should be reserved for more invasive infections like pyelonephritis, not uncomplicated cystitis 5
Treatment for Men
Men with UTI symptoms require different management 1, 2:
- Always obtain urine culture before treatment 2, 3
- Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 7 days (not 3 days as in women) 1, 4
- Consider prostatitis as a differential—if prostatitis cannot be excluded, extend duration to 14 days 2
- Alternative: nitrofurantoin 100 mg twice daily for 7 days 3
When to Skip Urine Culture in Women
Urine culture is NOT routinely needed for uncomplicated cystitis in women with typical symptoms (dysuria, frequency, urgency, no vaginal discharge) 1, 2, 3. Self-diagnosis with typical symptoms is sufficiently accurate 3.
Obtain urine culture when 1, 2:
- Suspected acute pyelonephritis
- Symptoms persist or recur within 4 weeks after treatment
- Atypical presentation
- Pregnancy
- Recurrent infections
- Treatment failure
- History of resistant organisms
Symptomatic Treatment Alternative
For women with mild to moderate symptoms, ibuprofen alone may be considered as an alternative to antibiotics after shared decision-making 1. However, this carries a small risk of progression to pyelonephritis, so immediate antibiotic therapy is generally preferred 3, 5.
Common Pitfalls to Avoid
- Do not use β-lactams (amoxicillin, amoxicillin-clavulanate) as first-line empiric therapy—they are less effective than recommended agents 5
- Do not use fluoroquinolones for simple cystitis—reserve for pyelonephritis or complicated infections 5
- Do not routinely obtain post-treatment cultures in asymptomatic patients 1
- Do not treat asymptomatic bacteriuria except in pregnant women or before invasive urologic procedures 2
Treatment Failure or Recurrence
If symptoms do not resolve by end of treatment or recur within 2 weeks 1:
- Obtain urine culture and susceptibility testing
- Assume the organism is not susceptible to the original agent
- Retreat with a 7-day regimen using a different antibiotic class 1