Treatment of Uncomplicated UTI in Non-Pregnant Adults
For uncomplicated cystitis in non-pregnant adult women, nitrofurantoin (50-100 mg four times daily for 5 days) or fosfomycin trometamol (3g single dose) are the recommended first-line treatments. 1, 2
First-Line Antibiotic Options for Women
The 2024 European Association of Urology guidelines establish clear first-line agents that balance efficacy against common uropathogens while minimizing collateral damage to normal flora: 1
- Fosfomycin trometamol: 3g single dose 1, 3
- Nitrofurantoin: 50-100 mg four times daily for 5 days (or 100 mg twice daily for 5 days for monohydrate/macrocrystal formulations) 1, 2
- Pivmecillinam: 400 mg three times daily for 3-5 days 1
These agents are preferred because they maintain high efficacy while avoiding broad-spectrum antibiotics that drive resistance. 2
Alternative Second-Line Options for Women
When first-line agents 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: 200 mg twice daily for 5 days 1
- Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days 1, 4
Critical caveat: Fluoroquinolones and trimethoprim-sulfamethoxazole should NOT be used as first-line empiric therapy due to rising resistance rates and the need to preserve these agents for complicated infections. 2, 5, 6 Real-world data shows TMP/SMX has higher treatment failure rates compared to nitrofurantoin. 7
Treatment for Men
Men with uncomplicated UTI require longer treatment duration: 1
- Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 7 days 1
- Fluoroquinolones may be used based on local susceptibility patterns 1
- Nitrofurantoin: Can be used for 7 days 8
Men should always have urine culture obtained to guide therapy, as the differential includes urethritis and prostatitis. 8
Diagnostic Approach
Clinical diagnosis alone is sufficient for women with typical symptoms (dysuria, frequency, urgency) without vaginal discharge - this approach has >90% accuracy. 1, 2
Urine culture is NOT routinely needed for straightforward uncomplicated cystitis but IS indicated for: 1, 2
- Suspected pyelonephritis
- Symptoms not resolving or recurring within 4 weeks after treatment
- Atypical symptoms
- Pregnant women
- All men with UTI symptoms 8
Non-Antibiotic Management Option
For women with mild to moderate symptoms, symptomatic treatment with NSAIDs (e.g., ibuprofen) may be considered as an alternative to immediate antibiotics after shared decision-making with the patient. 1, 2 This approach recognizes that many uncomplicated UTIs are self-limited with low complication risk. 1
Critical Pitfalls to Avoid
- Do NOT use fluoroquinolones as first-line empiric therapy - reserve for complicated infections and pyelonephritis given FDA safety warnings and resistance concerns 2, 5, 6
- Do NOT treat asymptomatic bacteriuria unless the patient is pregnant or undergoing urological procedures breaching the mucosa 1, 2
- Do NOT obtain routine post-treatment urine cultures in asymptomatic patients 1
- Do NOT perform imaging or cystoscopy for uncomplicated recurrent UTIs in women under 40 without risk factors 1, 2
Treatment Failure Management
If symptoms persist at end of treatment or recur within 2 weeks: 1
- Obtain urine culture with susceptibility testing
- Assume the organism is resistant to the initial agent
- Retreat with a 7-day course of a different antibiotic 1