What is the treatment for Escherichia coli (E. coli) urinary tract infection (UTI)?

From the Guidelines

Treatment for E. coli urinary tract infections should be guided by the most recent and highest quality evidence, which recommends using antibiotics such as nitrofurantoin or trimethoprim-sulfamethoxazole as first-line treatment, with consideration of local resistance patterns and urine culture results 1.

Key Considerations

• The choice of antibiotic should be based on local resistance patterns and urine culture results, as resistance rates can vary significantly between regions and countries 1.
• For uncomplicated cases, nitrofurantoin (Macrobid) 100 mg twice daily for 5 days or trimethoprim-sulfamethoxazole (Bactrim) 160/800 mg twice daily for 3 days can be used as first-line treatment.
• For more complicated infections, fluoroquinolones like ciprofloxacin 500 mg twice daily for 7-14 days may be used, but only if the local resistance rate is <10% 1.

Important Factors to Consider

• Local resistance patterns and urine culture results should guide antibiotic choice.
• Patients should complete the full course of antibiotics even if symptoms improve quickly.
• Drinking plenty of water helps flush bacteria from the urinary system.
• Those with recurrent infections may need longer treatment courses or prophylactic antibiotics.

Recent Guidelines

• The European Association of Urology guidelines recommend using a combination of antibiotics, such as amoxicillin plus an aminoglycoside, or a second-generation cephalosporin plus an aminoglycoside, for complicated UTIs 1.
• The guidelines also recommend avoiding ciprofloxacin and other fluoroquinolones for empirical treatment of complicated UTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months 1.

From the FDA Drug Label

Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis Levofloxacin tablets are indicated for the treatment of uncomplicated urinary tract infections (mild to moderate) due to Escherichia coli, Klebsiella pneumoniae, or Staphylococcus saprophyticus. For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris

Treatment for E. coli in urine:

• Levofloxacin (PO) is indicated for the treatment of uncomplicated and complicated urinary tract infections due to Escherichia coli 2.
• Trimethoprim-sulfamethoxazole (PO) is indicated for the treatment of urinary tract infections due to susceptible strains of Escherichia coli 3.

From the Research

Treatment Options for E. coli in Urine

• The recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females is a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 4.
• High rates of resistance for trimethoprim-sulfamethoxazole and ciprofloxacin preclude their use as empiric treatment of UTIs in several communities, particularly if patients who were recently exposed to them or in patients who are at risk of infections with extended-spectrum β-lactamases (ESBLs)-producing Enterobacteriales 4.
• Second-line options include oral cephalosporins such as cephalexin or cefixime, fluoroquinolones and β-lactams, such as amoxicillin-clavulanate 4.
• Treatment oral options for UTIs due to ESBLs-E coli include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 4, 5.
• More than 95% of all ESBL producing Enterobacteriacae were sensitive to pivmecillinam, fosfomycin and nitrofurantoin 5.
• The emergence of multidrug resistant ESBL producing Enterobacteriacae restricts significantly the therapeutic options, and the use of pivmecillinam, fosfomycin and nitrofurantoin is recommended to treat uncomplicated UTIs due to ESBL producing Enterobacteriacae 5.

Resistance to Antibiotics

• The resistance rate for trimethoprim-sulfamethoxazole was 34% and all of the resistant microorganisms were E. coli 6.
• The resistance rate for fluoroquinolones was 16.4% and resistant microorganisms were E. coli 6.
• Three predictors of trimethoprim-sulfamethoxazole resistance were identified: recurrent UTI, genitourinary abnormalities, and trimethoprim-sulfamethoxazole use within 90 days 7.
• Trimethoprim-sulfamethoxazole should likely be avoided as first-line therapy for UTI in patients who have recurrent UTIs, genitourinary abnormalities, or have previously received trimethoprim-sulfamethoxazole within the past 90 days 7.

Efficacy of Nitrofurantoin

• The clinical cure rates in nitrofurantoin ranged from 51 to 94% depending on the length of follow-up, and bacteriological cure rates ranged from 61 to 92% 8.
• Overall the evidence suggests that nitrofurantoin is at least comparable with other uUTI treatments in terms of efficacy 8.
• Patients taking nitrofurantoin reported fewer side effects than other drugs and the most commonly reported were gastrointestinal and central nervous system symptoms 8.