What is the diagnosis and treatment for a urinary tract infection (UTI)?

From the Guidelines

For the treatment of recurrent uncomplicated urinary tract infections (UTIs) in women, clinicians should use first-line therapy such as nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, dependent on the local antibiogram, and treat with as short a duration of antibiotics as reasonable, generally no longer than seven days 1.

Key Considerations

• The choice of antibiotic should be guided by the local antibiogram to minimize the risk of resistance and ensure effective treatment.
• Treatment duration should be as short as possible to reduce the risk of antibiotic resistance and minimize side effects.
• First-line agents such as nitrofurantoin, TMP-SMX, and fosfomycin are effective and less likely to produce collateral damage compared to second-line agents.

Patient Management

• Patients with recurrent UTIs should be advised on self-care measures, including adequate hydration, urge-initiated voiding, post-coital voiding, and avoidance of spermicidal-containing contraceptives.
• Topical vaginal estrogens may be prescribed for postmenopausal women with risk factors such as atrophic vaginitis.
• Imaging studies are not routinely recommended for patients with recurrent UTIs without underlying risk factors or complications.

Antibiotic Prophylaxis

• Antibiotic prophylaxis may be considered for women who experience three or more symptomatic infections over a 12-month period.
• Self-start antibiotic therapy can be considered in reliable patients who are willing to obtain urine specimens before starting therapy and communicate effectively with their provider.
• Nitrofurantoin is a preferred first-line agent for re-treatment due to its low resistance rate and quick decay of resistance if present 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Urinary Tract Infections (UTIs)

• UTIs are a growing concern due to limited treatment options and increasing antimicrobial resistance 2
• The most common uropathogens include Escherichia coli, which is often resistant to trimethoprim-sulfamethoxazole and fluoroquinolones 3, 4

Treatment Options

• First-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis includes:
  • Nitrofurantoin (5-day course)
  • Fosfomycin tromethamine (3-g single dose)
  • Pivmecillinam (5-day course) 2, 3
• Second-line options include oral cephalosporins, fluoroquinolones, and β-lactams such as amoxicillin-clavulanate 2
• Treatment options for UTIs due to ESBL-producing Enterobacteriales include nitrofurantoin, fosfomycin, and carbapenems 2

Antibiotic Resistance

• High rates of resistance to trimethoprim-sulfamethoxazole and fluoroquinolones have been reported, making treatment choices more complex 2, 4
• The use of new antimicrobials should be done wisely to avoid resistance development 2
• Resistance rates against fluoroquinolones are as high as 16.4%, making empiric use potentially problematic 4

Diagnosis and Prevention

• Diagnosis of uncomplicated UTIs is usually made based on clinical presentation, whereas complicated UTIs require more complex diagnosis 5
• Prevention of recurrent cystitis aims to minimize antimicrobial use, with research efforts focused on developing effective and safe antimicrobial-sparing approaches 5