What is the appropriate treatment for a patient with a urinary tract infection (UTI)?

Treatment of Urinary Tract Infections

For uncomplicated UTIs in women, treat with 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%), without obtaining urine culture in typical presentations. 1, 2

Uncomplicated Cystitis in Women

First-Line Treatment Options

• Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is the preferred first-line agent due to minimal resistance patterns and low collateral damage to normal flora 1, 2
• Fosfomycin trometamol 3 g as a single dose offers excellent patient compliance with convenient single-dose therapy, though slightly lower efficacy than nitrofurantoin 1, 2
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days should only be used if local resistance rates are <20% or if the infecting organism is known to be susceptible 1, 3

When to Obtain Urine Culture

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

• Suspected acute pyelonephritis is present
• Symptoms fail to resolve 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) 2

Avoid These Common Pitfalls

• Do NOT use fluoroquinolones (ciprofloxacin, levofloxacin) as first-line therapy for uncomplicated cystitis—reserve these for complicated infections or pyelonephritis to preserve efficacy and minimize resistance 1, 2
• Do NOT treat asymptomatic bacteriuria except in pregnant women or before invasive urologic procedures, as treatment increases antimicrobial resistance and paradoxically increases recurrent UTI episodes 1, 2
• Do NOT perform routine post-treatment urinalysis or cultures in asymptomatic patients 1

Complicated UTIs

Defining Complicating Factors

Complicated UTIs occur when host-related factors or anatomic/functional abnormalities make infection more challenging to eradicate, including: 2, 1

• Obstruction at any site in the urinary tract
• Foreign body or indwelling catheter
• Incomplete voiding or vesicoureteral reflux
• Recent instrumentation
• UTI in males
• Pregnancy
• Diabetes mellitus or immunosuppression
• Healthcare-associated infections
• ESBL-producing or multidrug-resistant organisms

Empiric Treatment for Complicated UTI with Systemic Symptoms

For hemodynamically unstable patients or those with systemic symptoms, use combination parenteral therapy: 2, 1

• Amoxicillin plus aminoglycoside, OR
• Second-generation cephalosporin plus aminoglycoside, OR
• Intravenous third-generation cephalosporin (e.g., ceftriaxone 1-2 g IV once daily)

Only use ciprofloxacin if local resistance rate is <10% when the entire treatment is given orally, the patient does not require hospitalization, or the patient has anaphylaxis to β-lactam antimicrobials 2

Do NOT use ciprofloxacin or other fluoroquinolones for empirical treatment in patients from urology departments or when patients have used fluoroquinolones in the last 6 months 2

Treatment Duration

• Standard duration is 7 days for most complicated UTIs 2, 1
• Extend to 14 days for men when prostatitis cannot be excluded 2
• When the patient is hemodynamically stable and afebrile for at least 48 hours, a shorter 7-day duration may be considered 2

Critical Management Principles

• Always obtain urine culture and susceptibility testing before initiating antibiotics for complicated UTIs 1, 2
• Tailor empiric therapy based on culture results once susceptibility data returns 1, 2
• Address the underlying urological abnormality or complicating factor—antimicrobial therapy alone is inadequate without correcting the underlying problem 2

Acute Pyelonephritis

Oral Step-Down Therapy Options (once hemodynamically stable and afebrile)

• Ciprofloxacin 500-750 mg twice daily for 7 days total (if local resistance <10%) 1, 4
• Levofloxacin 750 mg once daily for 5 days total (if local resistance <10%) 1, 4
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days total 1
• Cefpodoxime 200 mg twice daily for 10 days total 1

Recurrent UTIs

Definition and Diagnostic Approach

Recurrent UTIs are defined as ≥3 UTIs per year or ≥2 UTIs in 6 months 1, 2

• Obtain urine culture with each symptomatic episode prior to treatment 1, 2
• Patient-initiated treatment (self-start) may be offered to select reliable patients while awaiting cultures, provided they obtain urine specimens before starting therapy and communicate effectively with their provider 2, 1

Prevention Strategies by Population

For postmenopausal women: 2, 1

• Vaginal estrogen therapy with or without lactobacillus-containing probiotics is the first-line preventive strategy
• This reduces future UTI risk with moderate-quality evidence

For premenopausal women with post-coital infections: 2, 1

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

For premenopausal women with infections unrelated to sexual activity: 2, 1

• Daily antibiotic prophylaxis (nitrofurantoin preferred due to low resistance)
• Methenamine hippurate and/or lactobacillus-containing probiotics as nonantibiotic alternatives

Behavioral Modifications

Educate patients on: 2

• Ensuring adequate hydration to promote more frequent urination
• Encouraging urge-initiated voiding and post-coital voiding
• Avoiding spermicidal-containing contraceptives

Management of Treatment Failure

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

• Obtain repeat urine culture with antimicrobial susceptibility testing before prescribing additional antibiotics
• Assume the organism is not susceptible to the initially used agent
• Retreat with a 7-day regimen using a different antimicrobial class based on culture results
• Evaluate for underlying complicating factors if rapid recurrence occurs with the same organism, including obstruction, incomplete bladder emptying, struvite stones, diabetes, immunosuppression, or foreign body 2, 1