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Medications
Antibiotics are the mainstay treatment for all UTIs. A variety of antibiotics are available and
choices depend on many factors, including whether the infection is complicated or
uncomplicated or primary or recurrent. Treatment decisions are also based on the type of patient
(e.g., man or woman, a pregnant or nonpregnant woman, child, hospitalized or nonhospitalized
patient, person with diabetes.) Treatment should not necessarily be based on the actual bacteria
count. or e!ample, if a woman has symptoms, even if bacterial count is low or normal, infection
is probably present and antibiotic treatment should be considered.
Bacterial Resistance to Antibiotics. "f ma#or concern for doctors and the public is the emergence
of strains of common bacteria, including E. coli, that are resistant to specific antibiotics. The
prevalence of such bacteria has dramatically increased worldwide, in large part due to
widespread use of antibiotics in people and animal feeds.
$esistance to antibiotics is most often observed in the hospital setting. Unfortunately, there has
been a ma#or worldwide increase within the community in E. coli resistance to standard
antibiotics used for UTIs. A ma#or study, the %&".'%(' )ro#ect, has been designed to
investigate resistant UTI bacteria in *+ %uropean countries. In a ,--. report, /,0 of E. coli were
resistant to one or more of the *, antibiotics investigated. $esistance was highest to ampicillin
(,1.20). $esistance to T3)4'35 (6actrim, &otrim, 'eptra) was */.*0. (E. coli is the most
common bacteria in urinary tract infections.) $esistance to other common UTI antibiotics,
including mecillinam, cefadro!il, nitrofurantoin, fosfomycin, gentamicin, and ciproflo!acin still
averaged under .0. The rates vary, however, depending on regions. In general, regions and
institutions with the highest rate of resistance are those in which antibiotics are heavily
prescribed. In the %uropean study, for e!ample, resistance rates were highest in )ortugal and
'pain and lowest in the (ordic countries and Austria.
Specific nti!iotics "sed for Most "#$s
Beta-Lactams
The beta-lactam antibiotics share common chemical features and include penicillins,
cephalosporins, and some newer similar agents. Their primary actions to interfere
with bacterial cell walls. Many have been important in the treatment of urinary tract
infections.
Penicillins (Amoxicillin). Until recent years, the standard treatment for a UTI was 10
days of amoicillin, a penicillin antibiotic, but it is now ine!ective against E. coli
bacteria in up to "#$ of cases. % combination of amoicillin-clavulanate
&%ugmentin' is sometimes given for drug-resistant infections. %moicillin or
%ugmentin may be useful for UTIs caused by gram-positive organisms, including
Enterococcus species and S. saprophyticus.
Cephalosporins. %ntibiotics (nown as cephalosporins are also alternatives for
infections that do not respond to standard treatments or for special populations.
They are often classed in the following)
*irst generation includes cephalein &+e,e', cefadroil &-uricef, Ultracef',
and cephradine &.elosef'.
/econd generation include cefaclor &0eclor', cefuroime &0eftin', cefpro1il
&0ef1il', and loracarbef &2orabid'.
Third generation include cefpodoime &.antin', cefdinir &3mnicef' cefditoren
&/prectracef', ce4ime &/upra', and ceftibuten &0ede'. 0eftriaone
&5ocephin' is an in6ected cephalosporin. These are e!ective against a wide
range of gram-negative bacteria.
Other Beta-Lactam Agents. 3ther beta-lactam antibiotics have been developed. *or
eample, pivmecillinam &a form of mecillinam', is commonly used in 7urope for
UTIs. It appears to be safe during pregnancy.
Trimethoprim-Sulfamethoxazole (TMP-SMX)
The current typical treatment is a three-day course of the combination drug
trimethoprim-sulfamethoa1ole, commonly called TM8-/M9 &:actrim, 0otrim,
/eptra'. % one-day course is somewhat less e!ective but poses a lower ris( for side
e!ects. 2onger courses &; to 10 days'wor( no betterthan the three-day course and
have a higher rate of side e!ects. TM8-/M9 should not be used in patients whose
infections occurred after dental wor( or in patients allergic to sulfa drugs. %llergic
reactions can be very serious. Trimethoprim &8roloprim, Trimpe' is sometimes used
alone in those allergic to sulfa drugs. TM8-/M9 can interfere with the e!ectiveness
of oral contraceptives. <igh rates of bacterial resistance to TM8-/M9 are being
observed in parts of the U/, such as the /outheast, /outhwest, and southern
0alifornia. /till, even when regional rates approach =0$, cure rates with TM8-/M9
reach >0$ to >#$.
Fluoroquinolones (Quinolones)
*luoro?uinolones &also simply called ?uinolones' interfere with the bacteria@s
genetic material so they cannot reproduce. They are the standard alternatives to
TM8-/M9. 7amples of ?uinolones include o,oacin &*loacin', cipro,oacin &0ipro',
nor,oacin &Aoroin', levo,oacin &2eva?uin', gati,oacin &Te?uin', and spar,oacin
&Bagam'. These antibiotics are e!ective against a wide range of organisms but are
epensive and, in general, used in the following circumstances)
In patients with complicated or catheter-induced UTIs.
In patients who do not respond or who are allergic to TM8-/M9.
In communities where there are high rates of bacteria resistant to TM8-/M9.
In elderly patients. % "001 study of older women with UTIs &mean age >0',
about half of whom were living in nursing homes, found that CD$ responded
to cipro,oacin, compared with >;$ to TM8-/M9.
%regnant women should not ta&e fluoro'uinolone anti!iotics. #hey also
ha(e more ad(erse effects in children than other anti!iotics and should not
!e the first)line option in most situations.
Antibiotics Used 'pecifically for UTIs
Nitrofurantoin. *itrofurantoin +,uradantin- Macrodantin. is a relati(ely
ine/pensi(e anti!iotic that is used specifically for urinary tract infections.
$t is an effecti(e alternati(e to #M%)SM0 or a 'uinolone. "nli&e many of
the other drugs- howe(er- it must !e gi(en se(en to 10 days- e(en in cases of
simple cystitis. +Shorter course treatments are !eing in(estigated.. $t is not
useful for treating &idney infections. *itrofurantoin fre'uently causes
stomach upset and interacts with many drugs. 2ther chronic or serious
medical conditions may also affect its use. $t should not !e used in
pregnant women within a wee& or two of deli(ery- in nursing mothers- or
in those with &idney disease.
Fosfomycin. #he anti!iotic fosfomycin +Monurol.- which comes in an
orange)fla(ored- solu!le powder- is pro(ing to !e another good alternati(e.
$t can !e an effecti(e one)dose treatment for many women- including those
who are pregnant. #o date- !acterial resistance rates to this anti!iotic are
(ery low.
Tetracyclines
#etracyclines inhi!it !acterial growth. #hey include do/ycycline-
tetracycline- and minocycline. 3ong)term treatment with tetracycline or
do/ycycline may !e used for infections that are caused !y Mycoplasma or
Chlamydia. #etracyclines ha(e uni'ue side effects among anti!iotics-
including s&in reactions to sunlight- possi!le !urning in the throat- and
tooth discoloration.
Aminoglycosides
minoglycosides +gentamicin- &anamycin- to!ramycin- ami&acin. are
gi(en !y in4ection for (ery serious !acterial infections. #hey can !e gi(en
only in com!ination with other anti!iotics. 5entamicin is the most
commonly used aminoglycoside for serious "#$s. #hey can ha(e (ery
serious side effects- including damage to hearing- sense of !alance- and
&idneys. #reatment for "ncomplicated "#$s
'tudies are now reporting that uncomplicated UTIs in low4ris7 women can often be successfully
treated over the phone. In such cases, a health professional, usually a nurse, provides the patients
with three4day antibiotic regimens without even re8uiring an office urine test. This course is now
recommended only for women at low ris7 for recurrent infection and who do not have symptoms
suggesting other problems, such as vaginitis. In some centers, women who are treated over the
phone have to be less than 99 years old: all other patients need to see a doctor for evaluation.
Antibiotic Regimen. "ral antibiotic treatment cures 1/0 of uncomplicated urinary tract
infections, although the rate of recurrence remains high. The following are antibiotics used for
uncomplicated UTIs.
The standard regimen is a three4day course of trimethoprim4sulfametho!azole, commonly
called T3)4'35 (6actrim, &otrim, 'eptra). A single oral dose of T3)4'35 is
sometimes prescribed in mild cases, but cure rates are generally lower (2+0) than with
the three4day regimens. (;onger4term therapy, given for seven to *- days, is now mostly
limited to men, children, the elderly, people with diabetes with any UTI, and women with
pyelonephritis or who are pregnant.)
An antibiotic called a fluoro8uinolone, such as ciproflo!acin (&ipro), is usually the
second choice. In fact, it is often the first choice where there are the high rates of
bacterial resistant to T3)4'35. luoro8uinolones can also be given in a three4day
course. )regnant women should not ta7e these drugs.
(itrofurantoin (uradantin, 3acrodantin) is a third option. Thisdrug must be given for
longer than three days.
osfomycin (3onurol) is not as effective as other antibioticsbut may be used during
pregnancy. $esistance rates to this drug are also very low.
After a wee7 of antibiotic treatment, most patients are free of infection. If the symptoms do not
clear up within the first few days of therapy, doctors generally suggest that women discontinue
their antibiotic and provide a urine sample for culturing in order to identify the specific organism
causing the condition.
Treatment for Relapsing Infection. A relapsing infection (caused by treatment failure) occurs
within three wee7s in about *-0 of women. $elapse is treated similarly to a first infection but
the antibiotics are continued for at least two wee7s. ($elapsing infections may be due to
structural abnormalities, abscesses, or other problems that may re8uire surgery, and such
conditions should be ruled out.)
nti!iotic #reatment for 6ecurrent $nfections
)reventive antibiotics may be re8uired for women who e!perience two or more symptomatic
UTIs within si! months or three or more over the course of a year. There are various approaches
that are available. A woman<s own perception of discomfort can generally guide her decisions on
whether to use preventive antibiotics or not. All women should use life4style measures to prevent
recurrences.
Intermittent Self Treatment. 3any, if not most, women with recurrent UTIs can effectively self
treat recurrent UTIs without going to a doctor. In general, she ta7es the following steps=
As soon as the patient develops symptoms, she ta7es the antibiotic. Infections that occur
less than twice a year are usually treated as if they were an initial attac7, with single4dose
or three4day antibiotic regimens.
At that time, she also performs a clean4catch urine test and sends it to the doctor for
culturing to confirm the infection.
A doctor should be consulted under the following circumstances=
If symptoms have not completely resolved within /2 hours.
If there is a change in symptoms.
If the patient suspects that she is pregnant.
If the patient has more than four infections a year.
>omen who are not good candidates for self4treatment are those who are unable to diagnose
themselves or women with impaired immune systems, previous 7idney infections, structural
abnormalities of the urinary tract, or a history of infection with antibiotic4resistant bacteria.
Postcoital Antibiotics. If recurrent infections are clearly related to se!ual activity and episodes
recur more than two times within a si!4month period, a single preventive dose ta7en immediately
after intercourse has proven to be very effective. Antibiotics in such cases include T3)4'35,
nitrofurantoin, cephale!in, or a fluoro8uinolone (such as ciproflo!acin). (luoro8uinolones are
not appropriate during pregnancy.)
Continuous Preventive Antibiotics (Prophylais!. &ontinuous preventive (prophylactic)
antibiotics are an option for some women who do not respond to other measures. >ith this
approach, low4dose antibiotics are ta7en continuously for si! months or longer.
Typical prophylactic regimens include one dose of nitrofurantoin (9- mg), *?, tablet of T3)4
'35, or cephale!in (,9- mg) daily. Ta7ing the antibiotic at bedtime may be most effective.
'tudies suggest that continuous prophylactic antibiotics reduces recurrences by up to 190 and
may prevent 7idney infection.
Adverse effects mostly include gastrointestinal problems and yeast infections. (Ta7ing probiotic
supplements or eating yogurt may help prevent yeast infections.) Although there is concern that
continuous ris7 increases the ris7 for bacteria that are resistant to the antibiotics, studies to date
have not reported any significant ris7 even up to five years of use.
nti!iotics for 7idney $nfections +%yelonephritis.
Treating "ncomplicate# $i#ney Infections. )atients with uncomplicated 7idney infections
(pyelonephritis) may be treated at home with oral antibiotics. 'uch patients are healthy and non
pregnant. They typically are e!periencing fever, chills, and flan7 pain. @owever, they are not
nauseous or vomiting and show no symptoms or signs of 7idney involvement or complicated
infection.
The standard treatment for uncomplicated pyelonephritis is a */4day course of oral antibiotics,
usually trimethoprim4sulfametho!azole (T3)4'35) or a fluoro8uinolone. 'ometimes patients
with uncomplicated pyelonephritis are first given an antibiotic in#ection, if indicated.
"ral amo!icillin or amo!icillin4clavulanate (Augmentin) may be prescribed for women with
bacteria that do not respond to standard regimens (e.g., gram4positive organisms, including
Enterococcus species and S. saprophyticus).
A urine culture is may be obtained within one wee7 of completion of therapy and again four
wee7s later.
Treating %o#erate to Severe $i#ney Infections. )atients with moderate to severe acute 7idney
infection and those with severe symptoms or other complications may need to be hospitalized. In
such cases, antibiotics (ceftria!one and gentamicin) are usually given intravenously for three to
five days or until symptoms are relieved and patients have not shown any signs of fever for ,/ to
/2 hours. "ne study reported that oral cefi!ime may be as effective as intravenous antibiotics in
small children with UTIs and fever. In any case, adult patients are switched to oral antibiotic
therapy after symptoms have subsided and continued for another two wee7s: treatment for longer
than this has no additional benefit.
If fever and bac7 pain persist after +, hours of antibiotic administration, the doctor will usually
order imaging tests to see if abscesses, obstructions, or other abnormalities are present.
Treating Chronic $i#ney Infections. )atients with chronic pyelonephritis are often treated with
long4term antibiotics, even during periods when they have no symptoms.
#reatments for $nterstitial 8ystitis
There are two approved treatments for interstitial cystitis= )entosan polysulfate (%lmiron), and
dimethyl sulfo!ide (A3'"). )atients generally prefer %lmiron because it can be ta7en by mouth.
A A3'" solution is instilled into the bladder through a catheter. %lmiron is a type of blood
thinner that helps to coat the bladder lining and prevent infections. It may ta7e several months
before it has an effect on symptoms, but its benefits increase the longer it is used.
9octors sometimes also prescri!e other types of medications to help interstitial
cystitis symptoms. #hese drugs include antihistamines such as hydro/y:ine
+tara/.- and low doses of the tricyclic antidepressant amitriptyline
+;la(il.. 9rugs that reduce !ladder spasms +hyoscine- o/y!utynin. are also
sometimes used. Some doctors thin& that interstitial cystitis may !e related
to immune disorders. 6esearchers are in(estigating (arious drugs that
!loc& immune and inflammatory responses. #reatments for Specific
%opulations
Treating the Pregnant &oman. )regnant women should be screened for UTIs, since they are at
high ris7 for UTIs and their complications. The antibiotics used during pregnancy are
amo!icillin, ampicillin, nitrofurantoin, or an oral cephalosporin. osfomycin (3onurol) is not as
effective as others but may be used during pregnancy. $esistance rates to this drug are also very
low. They should not ta7e fluoro8uinolones.
)regnant women with even asymptomatic bacteriuria (evidence of infection but no symptoms)
have a .-0 ris7 for acute pyelonephritis in their second or third trimester. Therefore they need
screening and treatment for this condition. In such cases, they should be treated with a short
course of antibiotics (three to five days). If this condition is recurrent, they can ta7e low4dose
nitrofurantoin. or an uncomplicated UTI, pregnant women may need longer4term antibiotics
(seven to *-) for urinary tract infections.
>omen with pyelonephritis have, to date, been hospitalized for treatment. "ne study suggested
that outpatient treatment may be safe and effective if the condition develops in the early months
of pregnancy. In the study, women were given an in#ection of ceftria!one in the emergency room,
observed for a few hours, and then administered a second in#ection. After this, they were sent
home with a prescription for an oral antibiotic.
Treating &omen 'ith (iabetes. >omen with diabetes have more fre8uent and more severe UTIs
than women without the disease. 3any e!perts recommend that patient with diabetes and UTI,
even an uncomplicated infection, be treated with antibiotics for seven to */ days. )eople with
diabetes have higher than average rates of asymptomatic bacteriuria, but it is unclear whether
they should be screened and treated for this condition. A ,--. study indicated that treating this
condition had little value in these women and did not prevent complications.
Treating "rethritis in %en. Urethritis in men has typically been treated with a seven4day regimen
of do!ycycline. 'ome research is showing that a single dose of azithromycin may be #ust as
effective while causing fewer side effects. "ne4dose treatment also improves compliance, so cure
rates may even be better than with a long4term regimen. "f concern, however, is an infection that
spreads to the prostate gland, which is harder to treat, so most doctors still prefer the longer
regimen. It should be noted that azithromycin and similar antibiotics do not cure the infection
and may mas7 the symptoms of an accompanying se!ually transmitted disease, such as
gonorrhea. Tests for such diseases should be conducted if urethritis is diagnosed.
Treating Chil#ren 'ith "TIs. &hildren with UTIs are generally treated with T3)4'35 or
cephale!in (Befle!). The optimal duration is unclear. In one ma#or ,--. analysis, a two4 to four4
day treatment was as effective as seven to */ days. If initial therapy fails, then one in#ection of
ceftria!one or *- days of intravenous gentamicin nearly always cure the infection. &hildren can
be treated effectively for acute pyelonephritis with oral cefi!ime ('upra!) or a short course (two
to four days) of an intravenous (IC) antibiotic (typically gentamicin given in one daily dose). The
IC antibiotic is then followed by an oral antibiotic.
%ither long4term antibiotics or surgery to correct vesicoureteral reflu! (CU$) are options to
prevent infections in children (particularly girls) with CU$. It is unclear if either approach is any
more effective than the other. 'tudies are finding no significant difference in 7idney damage
between children who are treated with antibiotics or surgery. Antibiotic treatment usually
continues for years with the idea that the condition will resolve when the child has grown. A
,--, study reported that continuous antibiotics prevented infection in +,0 of girls and all of
boys over more than two years. Antibiotics were stopped after about four years on average, and
/,0 e!perienced UTIs or 7idney infections afterward. The use of long4term antibiotics in CU$
is controversial, however. There have been few well4conducted studies, and in one study, there
was no difference in ris7 for UTI or 7idney damage between patients who were ta7ing the
antibiotics and those who weren<t. There is also the concern of increasing the rates of bacteria
that are resistant to common antibiotics.
Management of 8atheter)$nduced "rinary #ract $nfections
Preventing atheter-!n"uce" !nfections
0atheter-induced urinary tract infections are very common and preventive measures
are etremely important. 0atheters should not be used unless absolutely necessary,
and they should be removed as soon as possible. 5educing the ris( for infections
during long-term catheter use, however, remains problematic.
Catheter Coatings. 0atheter coatings, such as silver nitrate, antibiotics, and other
substances, are being tested and are showing some bene4ts, but the problem is still
not resolved. 3ne promising catheter &2o*ric' uses a so-called hydrophilic coating
consisting of 8.8 &polyvinyl pyrrolidone' and salt. It attracts water to the catheter
surface, putting up a water barrier to reduce friction. In a "00= study, it was
associated with signi4cantly fewer UTIs.
Intermittent se o! Catheters. If a catheter is re?uired for long periods, it is best to
use it intermittently if possible &as opposed to an indwelling catheter'. /ome doctors
recommend replacing it every two wee(s to reduce the ris( of infection and
irrigating the bladder with antibiotics between replacements.
"aily #ygiene. % typical catheter is one that has been preconnected and sealed and
uses a drainage bag system. To prevent infection, some of the following tips may be
helpful)
-rin( plenty of ,uids, including three glasses of cranberry 6uice a day.
The catheter tube should be free of any (nots or (in(s.
0lean the catheter and the area around the urethra with soap and water daily
and after each bowel movement. &Eomen should be sure to clean front to
bac(.'
Eash hands before touching the catheter or surrounding area.
Aever disconnect the catheter from the drainage bag without careful
instructions from a health professional on strict methods for preventing
infection.
+eep the drainage bag o! the ,oor.
/tabili1e the bag against the leg using tape or some other system.
#nti$iotics for atheter-!n"uce" !nfections
8atients using catheters who develop UTIs with symptoms should be treated for
each episode with antibiotics and the catheter should be removed, if possible. %
ma6or problem in treating catheter-related UTIs is that the organisms involved are
constantly changing. :ecause there are li(ely to be multiple species of bacteria,
eperts generally recommend an antibiotic that is e!ective against a wide variety of
microorganisms. These medications include those in the ,uoro?uinolone group and
drug combinations such as ampicillin plus gentamicin or imipenem plus cilastatin.
%lthough high bacteria counts in the urine &bacteriuria' occur in most catheteri1ed
patients, administering antibiotics to pre$ent a UTI is rarely recommended. Many
catheteri1ed patients do not develop symptomatic urinary tract infections even with
high bacteria counts. If bacteriuria occurs without symptoms, antibiotic therapy has
little bene4t if the catheter is to remain in place for a long period.
0atheteri1ation is accomplished by inserting a catheter &a hollow tube, often with and in,atable balloon
tip' into the urinary bladder. This procedure is performed for urinary obstruction, following surgical
procedures to the urethra, in unconscious patients &due to surgical anesthesia, coma, etc.', or for any
other problem in which the bladder needs to be (ept empty &decompressed' and urinary ,ow assured.
0atheteri1ation in males is slightly more diFcult and uncomfortable than in females because of the
longer urethra.
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