by Felix C.

Describe the treatment of complicated lower UTI.

  • 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.

Describe the treatment of recurrent UTI.

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.


Felix C.


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