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How is acute uncomplicated urinary infection treated?
Acute cystitis is a mucosal infection effectively treated with relatively short courses of antimicrobial agents that achieve high urinary concentrations. Recommended first-line empiric regimens are antimicrobials to which the infecting organism is susceptible and which will have limited impact on the gut flora. These include nitrofurantoin macrocrystals/monohydrate, fosfomycin or, where available, pivmecillinam.
Trimethoprim/sulfamethoxazole (TMP/SMX) 160/800 mg bid for 3 days or TMP 100 mg bid for 3 days is effective but not recommended if local resistance prevalence of TMP/SMX for community-acquired organisms exceeds 20%. The fluoroquinolones—norfloxacin, ciprofloxacin, and levofloxacin—are effective given as a 3-day course, but are not recommended for first-line therapy because of concerns of safety and resistance emergence.
They are contraindicated in children because of adverse effects on cartilage development. The beta-lactam antimicrobials, such as amoxicillin, amoxicillin/clavulanic acid, and cephalosporins, are all 10% to 20% less effective for susceptible organisms than first-line agents and require a longer course of therapy, usually 7 days.
Antimicrobial Regimens for Empiric Treatment and for Prevention of Acute Uncomplicated Urinary Tract Infection
| Treatment | |
|---|---|
| First line | Nitrofurantoin 50–100 mg or nitrofurantoin macrocrystals 100 mg bid × 5 daysFosfomycin 3 g single dosePivmecillinam 400 mg bid × 5 days |
| Second line | TMP/SMX 160/800 mg bid × 3 daysTrimethoprim 100 mg bid × 3 daysCiprofloxacin 250 or 500 mg bid × 3 daysLevofloxacin 250 or 500 mg bid × 3 daysNorfloxacin 400 mg bid × 3 daysCephalexin 250–500 mg qid × 7 daysAmoxicillin/clavulanic acid 500 mg tid or 875 mg bid × 7 daysCefixime 400 mg qod × 7 daysDoxycycline 100 mg bid × 7 days |
| Prophylaxis | |
| Postintercourse (single dose) | Nitrofurantoin 50 mg or nitrofurantoin macrocrystals 100 mgTMP/SMX 40/200 mgTrimethoprim 100 mgCiprofloxacin 125 mgNorfloxacin 200 mgCephalexin 250 mg |
| Long-term low dose: (at bedtime) | Nitrofurantoin 50 mg qod or nitrofurantoin macrocrystals 100 mg qodTMP/SMX 40/200 mg qodTrimethoprim 100 mg odNorfloxacin 200 mg qodCiprofloxacin 125 mgCephalexin 500 mg qod |
TMP/SMX , Trimethoprim/sulfamethoxazole.
