What antibiotic should be given to a patient presenting with dysuria and hematuria, suggesting a possible urinary tract infection (UTI), with no known history of sulfa allergy or other contraindications?

Antibiotic Selection for Dysuria and Hematuria

For a patient presenting with dysuria and hematuria suggesting uncomplicated cystitis, nitrofurantoin (100 mg twice daily for 5 days) is the first-line treatment, with fosfomycin (3 g single dose) as an equally appropriate alternative. 1, 2

Clinical Context and Diagnosis

The combination of dysuria and hematuria strongly suggests acute bacterial cystitis, particularly in women without complicating factors. 3 Before initiating treatment, you must determine whether this is uncomplicated or complicated:

• Uncomplicated cystitis: Otherwise healthy, non-pregnant women with no anatomical/functional urinary tract abnormalities 1
• Complicated UTI: Presence of male sex, pregnancy, catheter, structural abnormalities, recent instrumentation, immunosuppression, or diabetes 4, 5

All UTIs in men are considered complicated and require 14 days of treatment, as prostatitis cannot be initially excluded. 4

First-Line Treatment Options for Uncomplicated Cystitis

Preferred Agents

• Nitrofurantoin: 100 mg orally twice daily for 5 days 1, 2, 3

  • Maintains excellent sensitivity against most uropathogens 3
  • Minimal collateral damage and resistance development 2, 3
  • Avoid in patients with creatinine clearance <30 mL/min 6

• Fosfomycin tromethamine: 3 g single oral dose 1, 2, 3

  • Convenient single-dose therapy with high patient compliance 2
  • Effective against ESBL-producing organisms 2, 7
  • Particularly useful when resistance patterns are unknown 1

Second-Line Options (When First-Line Unavailable)

• Trimethoprim-sulfamethoxazole: 160/800 mg (double-strength) twice daily for 3 days 1
  • Only use if local resistance rates are <20% 1, 3
  • Obtain urine culture if empirically used in areas with unknown resistance 1
  • High resistance rates in many communities now preclude routine use 2, 7

Treatment for Complicated UTI or Pyelonephritis

If the patient has fever, costovertebral angle tenderness, systemic symptoms, or complicating factors, this represents pyelonephritis or complicated UTI requiring different management:

Outpatient Treatment (No Hospitalization Required)

• Ciprofloxacin: 500 mg orally twice daily for 7 days 1

  • Only if local fluoroquinolone resistance is <10% 1
  • If resistance >10%, give initial IV ceftriaxone 1 g before starting oral therapy 1

• Levofloxacin: 750 mg orally once daily for 5 days 1

  • Same resistance threshold considerations apply 1

Alternative for Complicated UTI

• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 14 days 1
  • Only if organism known to be susceptible 1
  • If susceptibility unknown, give initial IV ceftriaxone 1 g or aminoglycoside 1

Duration Considerations

• Uncomplicated cystitis: 3-5 days 1, 2
• Complicated UTI: 7-14 days 4, 5
• Men (prostatitis cannot be excluded): Minimum 14 days 4
• Pyelonephritis: 7-14 days depending on agent 1

Critical Pitfalls to Avoid

Do not treat asymptomatic bacteriuria except in pregnancy or before invasive urological procedures. 1, 4 This increases resistance without clinical benefit and is a common error in older adults with positive urine cultures but no UTI symptoms. 1

Fluoroquinolones should not be used as first-line for uncomplicated cystitis due to increasing resistance rates and the need to preserve these agents for complicated infections. 1, 2, 7 The high resistance rates in many communities (often >10%) make empiric use problematic. 1

Beta-lactams (including amoxicillin-clavulanate) are less effective than other agents for pyelonephritis and should only be used with initial parenteral therapy if chosen. 1

Special Populations

Older Adults

Antimicrobial treatment in older patients follows the same principles as other age groups, using identical antibiotics and durations unless complicating factors exist. 1 Fosfomycin, nitrofurantoin, pivmecillinam, fluoroquinolones, and trimethoprim-sulfamethoxazole show only slight, insignificant age-associated resistance effects. 1

Pregnancy

Beta-lactams, nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are appropriate treatments in pregnancy. 3 All UTIs in pregnancy are considered complicated and require urine culture. 5

When to Obtain Urine Culture

Always obtain urine culture before treatment in:

• Suspected pyelonephritis 1
• Complicated UTI 4, 5
• Pregnancy 5
• Men (all UTIs) 4
• Failed initial therapy 5
• Recurrent infections 4

For uncomplicated cystitis in women with typical symptoms, empiric treatment without culture is acceptable if using first-line agents. 1, 3