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

Treatment for Bladder Infection in Otherwise Healthy Adults

For women with uncomplicated cystitis, first-line treatment is nitrofurantoin 100 mg twice daily for 5 days, fosfomycin trometamol 3 g single dose, or trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days; for men, trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is the recommended first-line regimen. 1, 2

For Women with Uncomplicated Cystitis

First-Line Antibiotic Options

The 2024 European Association of Urology guidelines provide three equally acceptable first-line choices 1:

• Fosfomycin trometamol 3 g as a single dose - most convenient option with excellent compliance 1
• Nitrofurantoin 100 mg twice daily for 5 days - maintains excellent activity against common uropathogens despite widespread use 1, 3
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days - only if local E. coli resistance is <20% 1, 3

When to Avoid Trimethoprim-Sulfamethoxazole

Do not use trimethoprim-sulfamethoxazole empirically if 4, 3:

• Local resistance rates exceed 20%
• Recent antibiotic exposure within past 3 months
• Recent hospitalization or healthcare contact
• Risk factors for ESBL-producing organisms (recent travel to high-resistance areas, previous ESBL infection)

Alternative Options

If first-line agents cannot be used 1:

• Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) - only if local E. coli resistance <20% 1
• Fluoroquinolones (ciprofloxacin or levofloxacin) - reserve for more serious infections due to collateral damage and resistance concerns 1, 3

Non-Antibiotic Approach

For women with mild to moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to immediate antibiotics after discussing risks and benefits 1. However, immediate antimicrobial therapy is more effective than delayed treatment 3.

When to Obtain Urine Culture

Urine culture is not needed for typical uncomplicated cystitis in women with classic symptoms 1. However, obtain culture before treatment if 1:

• Suspected pyelonephritis (fever, flank pain, systemic symptoms)
• Symptoms persist or recur within 4 weeks after treatment
• Atypical presentation
• Pregnancy

For Men with Bladder Infection

First-Line Treatment

Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is the recommended first-line regimen 1, 2, 5. Men require longer treatment duration than women because 2:

• Male UTIs are considered complicated by definition
• Potential prostatic involvement cannot be excluded
• Higher risk of treatment failure with shorter courses

Treatment Duration Decision

The duration depends on clinical response 2:

• 7 days if patient becomes afebrile within 48 hours with clear clinical improvement 2
• 14 days if prostatitis cannot be excluded or delayed response to therapy 2

Alternative Options for Men

When trimethoprim-sulfamethoxazole cannot be used 2:

• Ciprofloxacin 500 mg twice daily for 7-14 days 2
• Levofloxacin 750 mg once daily for 7-14 days 2

Critical Requirement for Men

Always obtain urine culture before initiating antibiotics in men 2. This is essential because:

• Men have higher rates of resistant organisms 2
• Broader spectrum of potential uropathogens (E. coli, Proteus, Klebsiella, Pseudomonas, Enterococcus) 2
• Allows adjustment based on susceptibility if initial therapy fails 2

Common Pitfalls to Avoid

Duration Errors

• Never treat men for only 3-5 days - minimum 7 days required due to complicated nature and prostatic involvement risk 1, 2
• Do not use single-dose fosfomycin in men - only validated for women with uncomplicated cystitis 1

Antibiotic Selection Errors

• Avoid fluoroquinolones as first-line when trimethoprim-sulfamethoxazole or nitrofurantoin are effective options 2, 3
• Beta-lactams (amoxicillin-clavulanate) are less effective than other first-line options for empiric therapy 3
• Moxifloxacin should not be used for UTI due to uncertain urinary concentrations 1

Diagnostic Errors

• Do not skip urine culture in men - this complicates management if empiric therapy fails 2
• In women with typical symptoms, dipstick testing adds minimal diagnostic value and treatment can begin based on symptoms alone 1

Post-Treatment Considerations

No Routine Follow-Up Testing

Routine post-treatment urinalysis or cultures are not indicated for asymptomatic patients 1

When Symptoms Persist or Recur

If symptoms do not resolve by end of treatment or recur within 2 weeks 1:

• Obtain urine culture with susceptibility testing
• Assume organism is not susceptible to initial agent
• Retreat with 7-day course using different antibiotic class