What is the recommended treatment for a patient with a urinary tract infection?

Treatment of Urinary Tract Infection

For uncomplicated UTIs in women, first-line treatment is nitrofurantoin 100 mg twice daily for 5 days, fosfomycin 3 g single dose, or trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (only if local resistance <20%). 1, 2

Uncomplicated Cystitis in Women

First-Line Options

• Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is preferred due to minimal resistance patterns and low collateral damage to normal flora 1, 2
• Fosfomycin trometamol 3 g as a single oral dose offers excellent compliance with convenient single-dose administration 1, 2
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days should only be used if local E. coli resistance rates are documented <20% or if the organism is known to be susceptible 1, 2, 3
• Pivmecillinam 400 mg three times daily for 3-5 days is an alternative in regions where available 1

When to Obtain Urine Culture

Urine culture is not routinely needed for typical uncomplicated cystitis presentations 1, 2. However, obtain culture when: 1, 2

• Suspected acute pyelonephritis (fever, flank pain, systemic symptoms)
• Symptoms persist or recur within 4 weeks after treatment completion
• Patient presents with atypical symptoms
• Patient is pregnant
• Patient is male (all UTIs in men are considered complicated) 1

Alternative to Antibiotics

For women with mild to moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to antimicrobials in consultation with the patient 1, 2

Management of Treatment Failure

If symptoms persist at end of treatment or recur within 2 weeks: 1, 2

• Obtain urine culture with antimicrobial susceptibility testing
• Assume the organism is not susceptible to the initially used agent
• Retreat with a 7-day regimen using a different antimicrobial class
• Do not perform routine post-treatment cultures in asymptomatic patients 1, 2

Uncomplicated Cystitis in Men

All UTIs in men are considered complicated and require 7 days of treatment. 1

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is the recommended first-line agent 1
• Obtain urine culture before initiating treatment 2
• Consider extending duration to 14 days if prostatitis cannot be excluded 1

Acute Pyelonephritis (Uncomplicated)

Empiric Parenteral Therapy for Severe Cases

For patients requiring hospitalization or unable to tolerate oral therapy: 2

• Ceftriaxone 1-2 g IV once daily
• Ciprofloxacin 400 mg IV twice daily (only if local resistance <10%)
• Levofloxacin 750 mg IV once daily (only if local resistance <10%)
• Gentamicin 5 mg/kg IV once daily

Oral Therapy for Mild-Moderate Cases

Once hemodynamically stable and afebrile for 48 hours, transition to oral therapy: 2

• Ciprofloxacin 500-750 mg twice daily for 7 days total (if local resistance <10%)
• Levofloxacin 750 mg once daily for 5 days total (if local resistance <10%)
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days total
• Cefpodoxime 200 mg twice daily for 10 days total

Complicated UTIs

Definition of Complicating Factors

Complicated UTIs occur when any of the following are present: 1, 2

• Obstruction at any site in urinary tract
• Foreign body (catheter, stent)
• Incomplete bladder emptying
• Vesicoureteral reflux
• Recent instrumentation
• Male gender
• Pregnancy
• Diabetes mellitus
• Immunosuppression
• Healthcare-associated infection
• ESBL-producing or multidrug-resistant organisms

Empiric Treatment for Complicated UTI with Systemic Symptoms

Use combination therapy with amoxicillin plus aminoglycoside, OR second-generation cephalosporin plus aminoglycoside, OR third-generation cephalosporin IV. 1

• Do not use ciprofloxacin empirically if local resistance >10%, patient is from urology department, or patient used fluoroquinolones in last 6 months 1
• Obtain urine culture and susceptibility testing before initiating antibiotics 2
• Treat for 7 days in most cases, extending to 14 days for men when prostatitis cannot be excluded 1, 2
• Address underlying urological abnormality or complicating factor 1

Catheter-Associated UTI

• Remove or replace catheter if possible before initiating treatment 1
• Obtain urine culture through newly placed catheter, not from existing catheter 1
• Treat with same regimens as complicated UTI based on severity and local resistance patterns 1
• Duration: 7-14 days depending on clinical response 1

Recurrent UTIs

Definition

≥3 UTIs per year OR ≥2 UTIs in 6 months 1, 2

Acute Treatment

• Obtain urine culture with each symptomatic episode prior to treatment 2
• Patient-initiated treatment (self-start therapy) may be offered to select patients while awaiting cultures 2
• Treat for as short a duration as reasonable, generally no longer than 7 days 2

Prevention Strategies

Postmenopausal women: 2

• Vaginal estrogen therapy (reduces future UTI risk)
• Lactobacillus-containing probiotics

Premenopausal women with post-coital infections: 2

• Low-dose antibiotic within 2 hours of sexual activity for 6-12 months

All women with recurrent UTIs: 2

• Increased fluid intake
• Cranberry products in tolerable formulations
• Daily antibiotic prophylaxis (nitrofurantoin or trimethoprim-sulfamethoxazole) if non-pharmacologic measures fail

Asymptomatic Bacteriuria

Do not screen for or treat asymptomatic bacteriuria except in pregnant women or before invasive urologic procedures. 1, 2

• Treatment increases antimicrobial resistance without clinical benefit 2
• Screen and treat in pregnant women with standard short-course treatment or single-dose fosfomycin 1
• Screen and treat before urological procedures breaching the mucosa 1

Febrile Infants and Children (2-24 Months)

Treatment Route

Oral or parenteral administration is equally efficacious; base choice on practical considerations 1

Empiric Parenteral Options

• Ceftriaxone 75 mg/kg every 24 hours 1
• Cefotaxime 150 mg/kg per day divided every 6-8 hours 1
• Gentamicin 7.5 mg/kg per day divided every 8 hours 1

Empiric Oral Options

• Amoxicillin-clavulanate 20-40 mg/kg per day in 3 doses 1
• Cefixime 8 mg/kg per day in 1 dose 1
• Cefpodoxime 10 mg/kg per day in 2 doses 1

Duration

7 to 14 days of antimicrobial therapy 1

Critical Pitfalls to Avoid

• Never use fluoroquinolones as first-line therapy for uncomplicated cystitis—reserve for complicated infections or pyelonephritis to preserve efficacy and minimize resistance 2
• Never treat asymptomatic bacteriuria (except in pregnant women or before invasive procedures)—this increases resistance and paradoxically increases recurrent UTI episodes 1, 2
• Never use nitrofurantoin for febrile UTIs or pyelonephritis—it does not achieve therapeutic bloodstream concentrations 1
• Never assume trimethoprim-sulfamethoxazole will work empirically—verify local resistance rates are <20% before using 1, 2
• Never perform routine post-treatment cultures in asymptomatic patients—this leads to unnecessary treatment of asymptomatic bacteriuria 1, 2