Guidelines for Treating Urinary Tract Infections (UTIs)

Diagnosis and Treatment

The European Urology guidelines recommend first-line treatment for uncomplicated cystitis in women to include fosfomycin trometamol (3g single dose), nitrofurantoin (100mg twice daily for 5 days), or pivmecillinam (400mg three times daily for 3-5 days), based on local resistance patterns 1, 2, 3, 4
Urine culture is recommended in suspected acute pyelonephritis, symptoms that do not resolve or recur within 4 weeks after treatment, women with atypical symptoms, pregnant women, and all cases of recurrent UTI 2, 3, 4
Fosfomycin trometamol is recommended as a 3g single dose for first-line treatment of uncomplicated cystitis in women 1, 2, 3, 4
Nitrofurantoin macrocrystals are recommended as 50-100mg four times daily for 5 days for first-line treatment of uncomplicated cystitis in women 1, 2, 3, 4
Pivmecillinam is recommended as 400mg three times daily for 3-5 days for first-line treatment of uncomplicated cystitis in women 1, 2, 3, 4
Trimethoprim-sulfamethoxazole is recommended as 160/800mg twice daily for 7 days for treatment of UTIs in men 1, 2, 3, 4
Fluoroquinolones can be prescribed according to local susceptibility testing for treatment of UTIs in men 1, 2, 3, 4

Ciprofloxacin is recommended as 500-750mg twice daily for 7 days for oral treatment of uncomplicated pyelonephritis 5
Levofloxacin is recommended as 750mg once daily for 5 days for oral treatment of uncomplicated pyelonephritis 5
Trimethoprim-sulfamethoxazole is recommended as 160/800mg twice daily for 14 days for oral treatment of uncomplicated pyelonephritis 5
Initial IV therapy with options including fluoroquinolones, aminoglycosides, extended-spectrum cephalosporins, or penicillins is recommended for parenteral treatment of uncomplicated pyelonephritis 5

Recurrent UTIs are defined as at least three UTIs per year or two UTIs in the last 6 months 1, 2, 3, 4
Increased fluid intake is recommended for premenopausal women as a non-antimicrobial prevention strategy for recurrent UTIs 4
Vaginal estrogen replacement is recommended for postmenopausal women as a non-antimicrobial prevention strategy for recurrent UTIs 4
Immunoactive prophylaxis is recommended as a non-antimicrobial prevention strategy for recurrent UTIs 4
Methenamine hippurate is recommended for women without urinary tract abnormalities as a non-antimicrobial prevention strategy for recurrent UTIs 4
Continuous or postcoital antimicrobial prophylaxis is recommended as an antimicrobial prophylaxis strategy for recurrent UTIs 4
Self-administered short-term antimicrobial therapy is recommended for patients with good compliance as an antimicrobial prophylaxis strategy for recurrent UTIs 4, 6

Complicated UTIs occur with host-related factors or anatomic/functional abnormalities 5
Treatment duration for complicated UTIs is 7-14 days (14 days for men when prostatitis cannot be excluded) 5
Appropriate management of underlying urological abnormality is mandatory for complicated UTIs 5

Asymptomatic bacteriuria should not be treated except in pregnant women or prior to urinary tract procedures 6
Surveillance urine testing should be omitted in asymptomatic patients with history of recurrent UTIs 6
Fluoroquinolones should be reserved for more invasive infections due to risk of "collateral damage" (selection of multi-resistant pathogens) 6
For women whose symptoms don't resolve by end of treatment or recur within 2 weeks, perform urine culture and antimicrobial susceptibility testing 1, 2
For retreatment, assume the infecting organism is not susceptible to the original agent and use a 7-day regimen with another agent 1, 2
Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 2