Management of Uncomplicated Urinary Tract Infection in Adults
For women with uncomplicated cystitis, first-line treatment consists of fosfomycin trometamol 3g single dose, nitrofurantoin 100mg twice daily for 5 days, or pivmecillinam 400mg three times daily for 3-5 days. 1
Diagnosis
Clinical diagnosis without urine culture is appropriate for typical presentations in women. 1
- Diagnose based on classic lower urinary tract symptoms: dysuria, frequency, urgency, and absence of vaginal discharge 1
- Urine dipstick or microscopy adds minimal diagnostic value when symptoms are typical 1
- Reserve urine culture for: suspected pyelonephritis, treatment failure or recurrence within 4 weeks, atypical symptoms, or pregnancy 1
Important caveat: In elderly women, genitourinary symptoms may not reliably indicate cystitis 1
First-Line Antibiotic Treatment for Women
The 2024 European Association of Urology guidelines prioritize these agents based on efficacy and minimal collateral damage (resistance selection): 1
Preferred Options:
- Fosfomycin trometamol: 3g single dose 1, 2
- Nitrofurantoin: 100mg twice daily for 5 days (monohydrate/macrocrystals or prolonged release formulations) 1
- Pivmecillinam: 400mg three times daily for 3-5 days 1
Alternative Options (when first-line unavailable or contraindicated):
- Cephalosporins (e.g., cefadroxil): 500mg twice daily for 3 days—only if local E. coli resistance <20% 1
- Trimethoprim: 200mg twice daily for 5 days (avoid first trimester pregnancy) 1
- Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days (avoid last trimester pregnancy) 1, 3
Critical consideration: Fluoroquinolones should be reserved for more invasive infections, not uncomplicated cystitis, due to resistance concerns and collateral damage 4, 5
Treatment for Men
Men require longer treatment duration—7 days minimum. 1
- Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1, 3
- Fluoroquinolones may be used according to local susceptibility patterns 1
- Always obtain urine culture before treatment in men 6
Non-Antibiotic Management Option
For women with mild-to-moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to immediate antibiotics after shared decision-making. 1
- Risk of progression to pyelonephritis is low (1-2%) 7
- This approach reduces antibiotic exposure and resistance selection 1, 7
- Patient must understand when to seek further care if symptoms worsen 7
Treatment Failure Management
If symptoms persist at treatment completion or recur within 2 weeks: 1
- Obtain urine culture with antimicrobial susceptibility testing 1
- Assume the organism is resistant to the initial agent 1
- Retreat with a different antibiotic for 7 days 1
Post-Treatment Monitoring
Do not perform routine post-treatment urinalysis or cultures in asymptomatic patients. 1
- Asymptomatic bacteriuria should not be screened for or treated in non-pregnant women 1
- Only retest if symptoms persist or recur 1
Common Pitfalls to Avoid
- Do not use fluoroquinolones as first-line therapy for uncomplicated cystitis—reserve for complicated infections or pyelonephritis 4, 5
- Do not treat asymptomatic bacteriuria in non-pregnant women, as this increases resistance without clinical benefit 1
- Do not prescribe β-lactams (amoxicillin-clavulanate) as first-line empiric therapy—they are less effective than recommended agents 5
- Avoid treatment courses longer than 7 days for uncomplicated cystitis 1, 6
- In elderly women, do not assume genitourinary symptoms equal UTI—consider alternative diagnoses 1