Treatment of uncomplicated UTIs

Addressing antimicrobial resistance in the treatment of uncomplicated UTIs

By Jairia Dela Cruz
02 Aug 2016, 01:00 AM

The susceptibility profile of causative bacteria and the potential collateral damage of treatments should be confirmed and considered when selecting appropriate antimicrobials in the management of acute uncomplicated cystitis (AUC) and pyelonephritis (AUP) for Asian patients, according to the UAA/AAUS* guidelines presented at the 14th Urological Association of Asia (UAA) Congress 2016 in Singapore.

Nitrofurantoin (100 mg BID for 5 to 7 days) is the first-choice treatment for AUC in countries where the drug is available, as follows: Singapore, China, and Russia. Other treatment alternatives are trimethoprim-sulfamethoxazole (TMP/SMZ; 1,600/800 mg BID for 3 days), fosfomycin trometamol (3 g for 1 day) or fosfomycin calcium (1 g TID for 2 days), cefaclor (250 mg TID for 7 days), cephalexin (250 mg QID for 7 days), and amoxicillin clavulanate (500/125 mg BID for 7 days), all of which are available in most Asian countries.

“The most important issue for uncomplicated urinary tract infections (UTIs) in Asia [however] is increasing fluoroquinolone resistance and extended-spectrum beta-lactamase (ESBL)-producing Gram-negative bacilli,” said Prof. Hiroshi Hayami from Kagoshima University Hospital.

In order to properly prescribe treatment, clinicians should identify the drug susceptibility of the strains, distinguishing between the coccus- and coli-forms of the uropathogen causing AUC, Hayami said. A way to do this is to perform a microscopic examination or flowcytometry.

For coli-form or unknown infections, the recommended first-line antimicrobials include fosfomycin, nitrofurantoin, TMP/SMZ, cephalexin, and amoxicillin clavulanate. Third-generation cephalosporins may also be used as an alternative.

Fluoroquinolones should be avoided for coli-form infections and indicated for those of coccus-form, particularly Staphylococcus saprophyticus. Another treatment option for coccus-form infections is amoxicillin clavulanate.


Pregnant women may be prescribed fosfomycin, nitrofurantoin, cephalexin, amoxicillin clavulanate as first-line agents for AUC, as well as third-generation cephalosporins as an alternative.

“In addition, urine culture is recommended for patients at high risk of high drug resistance,” Hayami said.