What is the recommended treatment for an otherwise healthy adult patient presenting with a urinary tract infection?

Treatment for Urinary Tract Infection in Otherwise Healthy Adults

For acute uncomplicated cystitis in otherwise healthy adult women, first-line treatment is a 3-day course of trimethoprim-sulfamethoxazole (160/800 mg twice daily), a 5-7 day course of nitrofurantoin (100 mg twice daily), or a single 3-gram dose of fosfomycin. 1, 2

Diagnostic Requirements Before Treatment

• Obtain urinalysis and urine culture before initiating antibiotics in patients with recurrent UTIs to document infection and guide therapy 3
• For first-time acute cystitis in young women with classic symptoms (acute-onset dysuria with urgency/frequency), diagnosis can be made clinically without office visit or culture 2
• Acute-onset dysuria has >90% accuracy for UTI in young women when vaginal irritation or discharge is absent 3

First-Line Antibiotic Choices

Preferred Agents (in order of preference):

1. Trimethoprim-sulfamethoxazole (TMP-SMX): 160/800 mg (1 DS tablet) twice daily for 3 days 1, 2

   • Critical caveat: Only use if local resistance rates are <20% and patient has no recent fluoroquinolone or TMP-SMX exposure 4
   • Avoid in communities with high resistance rates 3, 5

2. Nitrofurantoin monohydrate/macrocrystals: 100 mg twice daily for 5-7 days 4, 2

   • Excellent first-line option with minimal resistance development 4
   • Maintains activity against ESBL-producing organisms 4

3. Fosfomycin tromethamine: 3 grams as a single oral dose 4, 2

   • Convenient single-dose therapy 2
   • Effective against multidrug-resistant organisms including ESBL-producers 4

Second-Line Options

• Fluoroquinolones (ciprofloxacin, levofloxacin): Reserve for more invasive infections or when first-line agents are contraindicated 2

  • Should NOT be used empirically if local resistance exceeds 10% or recent fluoroquinolone exposure 6, 4

• β-lactams (amoxicillin-clavulanate, cephalexin, cefixime): Less effective as empirical therapy 4, 2

  • Consider only for culture-directed therapy after susceptibility confirmation 6

Treatment Duration by Clinical Scenario

• Uncomplicated cystitis in women: 3 days for TMP-SMX; 5-7 days for nitrofurantoin; single dose for fosfomycin 1, 2
• UTI in men: 7-14 days (14 days recommended when prostatitis cannot be excluded) 6, 2
• Complicated UTI with systemic symptoms: 7-14 days 6

Special Populations

Women with Diabetes

• Treat identically to women without diabetes if no voiding abnormalities present 2
• Use same first-line agents and durations 2

Recurrent UTI Patients

• Patient-initiated self-start treatment is appropriate for select patients while awaiting culture results 3
• Must have documented positive cultures from prior symptomatic episodes 3
• Obtain culture and sensitivity with each acute episode before treatment 3

Antimicrobial Stewardship Principles

• Avoid fluoroquinolones and broad-spectrum cephalosporins for uncomplicated cystitis to prevent resistance 3, 4
• Tailor therapy to shortest effective duration 3
• Consider local antibiogram patterns when selecting empirical therapy 3, 4
• β-lactams should be reserved for culture-directed therapy only 6, 2

Critical Pitfalls to Avoid

• Do NOT treat asymptomatic bacteriuria in non-pregnant, otherwise healthy adults—this promotes resistance without benefit 3, 7
• Do NOT use amoxicillin-clavulanate empirically for UTI without susceptibility confirmation 6
• Do NOT delay immediate antimicrobial therapy—symptom management with ibuprofen alone is inferior to prompt antibiotics 2
• Do NOT obtain cystoscopy or upper tract imaging routinely for uncomplicated recurrent UTI 3
• Do NOT use inadequate treatment duration—3-day courses are insufficient for men and may lead to treatment failure 6, 2