Treatment

• Antibiotic treatment is recommended for all patients with symptomatic UTI.

  • The optimal therapy depends on disease severity, local resistance patterns, and patient characteristics (e.g., allergies).

  • Initial treatment is with an empiric regimen, which is maintained for uncomplicated cystitis.

  • In unclear or complicated cases, the regimen may subsequently have to be adjusted based on urine culture data.

• Consider the need for supportive treatment.

  • Phenazopyridine, a urinary analgesic, can be used for symptomatic relief for a maximum of 2 days.

  • Oral analgesia, e.g., with NSAIDs, can provide additional relief.

• Management can typically be done in the outpatient setting with oral therapy.

• Treatment duration depends on the chosen antibiotic agent.

• Symptom relief can be expected to occur after an average of 36 hours. [29]

• Persistent symptoms despite antibiotic therapy suggest complicated UTI and/or indicate the need to change the empiric therapy.

Empiric antibiotic treatment of uncomplicated lower UTIs

• First-line treatment

  • Nitrofurantoin for 5 days

  • Trimethoprim/sulfamethoxazole (TMP/SMX) for 3 days

  • Fosfomycin (single dose)

• Second-line treatment: beta-lactam antibiotics for 5–7 days

  • Aminopenicillins plus beta-lactamase inhibitors, e.g., amoxicillin/clavulanic acid

  • Oral cephalosporins, e.g., cefpodoxime, cefdinir, or cefaclor

• Alternatives: Consider fluoroquinolones, e.g., ciprofloxacin for 3 days for patients with previous infections with bacteria resistant to other drug classes. [46]

• There are few recommendations for the empiric antibiotic treatment of complicated lower UTI.

  • Empiric antibiotic therapy should have broad-spectrum activity against the expected uropathogens.

  • Because UTIs in men can involve the prostate, antibiotics should be able to penetrate prostate tissue (e.g., fluoroquinolones, TMP/SMX).

• In addition to antibiotic therapy, complicating factors (e.g., obstruction) should be treated, if possible.

• For UTI in men, referral to urology may be warranted especially in the following cases:

  • Treatment failure or recurrent UTIs

  • Hematuria

  • Voiding difficulties or acute urine retention [23]

  • Suspected acute bacterial prostatitis

• Hospitalization and initial intravenous treatment may be necessary in the following cases: [15]

  • Severe systemic symptoms, e.g., signs of shock

  • Inability to tolerate oral antibiotics

  • Severe comorbidities, e.g., immunocompromise or heart failure

Antibiotic treatment of complicated lower UTIs [14][47]

• Antibiotic therapy must be adapted to culture results and is commonly given for 7–14 days.

• Options for the initial empiric treatment of complicated lower UTIs include:

  • Fluoroquinolones PO or IV: e.g., ciprofloxacin or levofloxacin

  • Beta lactams

    • Second-generation or third-generation cephalosporins: e.g., ceftriaxone

    • Extended-spectrum penicillins: e.g., ampicillin/sulbactam

• Reasonable options if the pathogen is susceptible include: [49]

  • Nitrofurantoin

  • TMP/SMX

  • Fosfomycin (multiple doses)

Treatment regimens for UTI in men should include antibiotics that are able to penetrate prostate tissue (e.g., fluoroquinolones or TMP/SMX). Fosfomycin or nitrofurantoin are generally not adequate.

Recurrent UTIs are common in women and are defined as ≥ 3 episodes of symptomatic, culture-proven UTI in one year or ≥ 2 episodes in 6 months. Management involves the implementation of preventive measures and antibacterial prophylaxis in addition to the antibiotic treatment of acute episodes.

Acute management

Whenever possible, obtain a urine culture for every episode prior to initiating antibiotic therapy.

• Choice of antibiotic

  • First recurrence: See “Antibiotic treatment for uncomplicated lower UTIs” and “Antibiotic treatment for complicated lower UTIs” for initial empiric regimens.

  • Frequent recurrences

    • Regimens should be tailored to the patient and prior culture results.

  • Antibiotics must be adapted to the current culture results once available.

Antibiotic prophylaxis [10]

• Indication: may be considered in all women with recurrent uncomplicated UTIs

• Continuous prophylaxis

  • Typically taken for 3–12 months with periodic reassessment

  • Regimens

    • Trimethoprim (TMP) daily

    • TMP/SMX daily

    • Cephalexin daily

    • Nitrofurantoin daily

    • Fosfomycin every 10 days

• Intermittent or postcoital prophylaxis

  • Recommended for women who have recurrent UTIs associated with sexual activity

  • Substances

    • TMP/SMX

    • Cephalexin

    • Nitrofurantoin

Nonantibiotic prophylaxis

• There is insufficient high-quality data to support the use of cranberry products for preventing UTIs. [55][56]

• Topical estrogen therapy should be considered in postmenopausal women.

• Behavioral modifications (e.g., increased fluid intake, postcoital voiding) may be helpful.

• General

  • Pyelonephritis

  • Perinephric abscess

  • Urosepsis

  • Emphysematous pyelonephritis

• In male individuals

  • Urethral stricture

  • Epididymitis

  • Prostatitis

  • Orchitis

• In pregnant women [58]

  • Increased risk of preterm labor and birth [59]

  • Hypertension and preeclampsia

  • Chorioamnionitis

• Behavioral modifications [60]

  • Increased fluid intake

  • Timely bladder voiding

  • Postcoital voiding

  • Adequate genital hygiene

• Clean intermittent catheterization

  • Indicated for individuals with neurogenic bladder

  • Reduces incidence of catheter-associated UTIs

• Prophylaxis: indicated for recurrent urinary tract infections