A Guide to Drugs for Uncomplicated Urinary Tract Infections

Urinary tract infections (UTIs) are very common, accounting for more than 10 million visits to doctors’ offices and 2 million to 3 million emergency department visits in the U.S. in 2007.[1] Half of all women will get a UTI at least once in their lives.[2] It is important for patients to understand when antibiotic treatments are necessary and which medications are the safest options.

About UTIs

A UTI is an infection that occurs anywhere along the urinary tract, which extends from the kidneys through the bladder and to the urethra, a tube that carries urine from the bladder out of the body. UTIs most often occur when infectious agents enter the urinary tract through the urethra.[3] Although viruses and fungi can lead to UTIs, the infections most commonly are caused by bacteria[4] — with E. coli, which is found in stool, the leading culprit.[5]

Although bacteria often are found in the urine during routine tests, they do not always cause symptoms. This condition, known as asymptomatic bacteriuria, requires treatment only in limited circumstances, such as during pregnancy and prior to urinary tract surgery.

UTIs generally are diagnosed only when symptoms occur. Symptoms may include pain or burning during urination, frequent urination, strong urges to urinate, and pain in the abdomen or groin. Patients with a UTI also can have a fever and cloudy or bloody urine, although these often are absent.

Because of their generally shorter urethras and for other anatomical reasons, women are at higher risk of getting a UTI than men.[6] Other risk factors for women include sexual activity, especially with a new partner; changes in vaginal bacteria; pregnancy; kidney stones;[7] and age less than 35.[8] In men, age greater than 65,[9] kidney stones and an enlarged prostate[10] increase the chances of getting a UTI.

(This article does not address “complicated” UTIs, which include UTIs in patients with catheters placed in the bladder, kidney failure, kidney stones, enlarged prostates, and immunosuppression or certain neurological conditions, and UTIs in pregnant women.)[11]

Treatment

The Infectious Diseases Society of America (IDSA) released guidelines in 2010 for treating UTIs in women.[12] The antibiotics nitrofurantoin (FURADANTIN, MACROBID, MACRODANTIN), trimethoprim-sulfamethoxazole (BACTRIM, SEPTRA, SULFATRIM) and fosfomycin (MONUROL) were recommended as first-choice medications due to their effectiveness and low rate of side effects. Fluoroquinolone antibiotics such as ciprofloxacin (CIPRO, CIPRO XR) and penicillin-like orgmedications were recommended as second-choice therapies because they are more dangerous than or generally not as effective as the first-choice medications.

A 2010 review found that trimethoprim-sulfamethoxazole, nitrofurantoin, fluoroquinolones and penicillin-like medications were similarly effective in resolving symptoms of UTIs in women.[13] In a 1999 study, a single dose of fosfomycin was as effective as a seven-day course of nitrofurantoin in curing uncomplicated UTIs in women.[14] A 2006 review determined that the different fluoroquinolones were equally effective in treating UTIs in women, but that the fluoroquinolone ofloxacin caused more side effects than other commonly used fluoroquinolones.[15]

Regarding how long antibiotics should be taken for uncomplicated UTIs, a 2005 review examining studies that tested a variety of different antibiotics found that three days of antibiotic treatment is as effective as five to 10 days of treatment in relieving UTI symptoms in women.[16] Another review found that in elderly women with symptomatic UTIs, antibiotic treatment for three to six days appeared to be as effective as treatment for seven to 14 days.[17]

In its 2005 guidelines, IDSA recommended against screening and treatment of asymptomatic bacteriuria in all patients except men undergoing prostate surgery and pregnant women.[18] A 2015 review analyzed all good studies of the treatment of asymptomatic bacteriuria that did not include pregnant women, patients with bladder catheters or other potentially high-risk patients.[19] It found that, while antibiotics were effective in clearing the bacteria from the urine, they did not prevent symptomatic UTIs, complications or death, and they came with a number of side effects.

Our take

Patients should not have their urine tested for bacteria and evidence of infection unless they have symptoms, are pregnant, recently have had a catheter removed or are about to undergo a surgical procedure on the urinary tract.

Patients with a UTI first should try nitrofurantoin, trimethoprim-sulfamethoxazole, or a one-time dose of fosfomycin. However, we recommend that patients older than 60 years of age not take nitrofurantoin due to more serious side effects in older patients.[20] If testing reveals that the bacteria causing the UTI are resistant to these three medications, only then should fluoroquinolones be used, though we recommend against using gemifloxacin [FACTIVE] or moxifloxacin [AVELOX].[21]

Patients given trimethoprim-sulfamethoxazole or nitrofurantoin for a UTI should be treated for only three to five days unless they are at high risk for severe complications from bacteria remaining in their urine after treatment — in which case doctors can continue antibiotics for up to two weeks.

Possible serious side effects of these antibiotics include:

• Lung disorders, liver and nerve damage, and anemia (nitrofurantoin).[22]
• Allergic reactions, platelet deficiency and congenital defects if taken while pregnant (trimethoprim-sulfamethoxazole).[23]
• Tendon rupture and tendinitis, nerve disorders, allergic reactions, white blood cell and platelet deficiency, liver damage, heart rhythm disorders,[24] and life-threatening damage to the body’s largest blood vessel, the aorta (fluoroquinolones).[25]
• Diarrhea with C. difficile bacteria (all of these antibiotics, in addition to fosfomycin).

What You Can Do

Women can reduce their chances of getting a UTI if they practice good genital and groin hygiene, stay hydrated, avoid douches and feminine hygiene sprays or powders, and urinate before and after sex, among other measures.[26]

Contrary to popular belief, cranberries do not appear to be effective in preventing UTIs.[27] The sole exception may be after gynecologic surgery, in which case cranberry supplement capsules (equivalent to about two eight-ounce glasses of cranberry juice) were shown to reduce the occurrence of UTIs by half.[28] However, we do not recommend taking most dietary supplements, as they are not well regulated by the Food and Drug Administration. Instead, talk with your doctor about the option of drinking two eight-ounce glasses of cranberry juice a day, for four to six weeks,[29] after gynecologic surgery.

Be watchful for symptoms of a UTI, such as pain during urination, frequent urination, abdominal or groin pain, cloudy or bloody urine, or fever. If you are diagnosed with a UTI, discuss the best treatment option with your doctor, including whether a short (three- to five-day) course of nitrofurantoin or trimethoprim-sulfamethoxazole — or a one-time dose of fosfomycin — would be sufficient to treat your infection.

If you are pregnant, are about to undergo urinary tract surgery or have had a catheter removed within the past two days, your urine should be tested, and if bacteria are detected, you should be treated with a full course of antibiotics. Otherwise, you should not be routinely screened or treated for bacteria in the urine unless you have symptoms of a UTI.

References

[1] Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol. 2015;13(5):269-284.

[2] National Institute of Diabetes and Digestive and Kidney Diseases. Urinary tract infection in adults. http://www.niddk.nih.gov/health-information/health-topics/urologic-disease/urinary-tract-infections-in-adults/Pages/facts.aspx. Accessed March 11, 2016.

[3] American Urological Association. Adult UTI. https://www.auanet.org/education/adult-uti.cfm. Accessed February 15, 2016.

[4] National Institute of Diabetes and Digestive and Kidney Diseases. Urinary tract infection in adults. http://www.niddk.nih.gov/health-information/health-topics/urologic-disease/urinary-tract-infections-in-adults/Pages/facts.aspx. Accessed March 11.

[5] Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol. 2015;13(5):269-284.

[6] National Institute of Diabetes and Digestive and Kidney Diseases. Urinary Tract Infection in Adults. http://www.niddk.nih.gov/health-information/health-topics/urologic-disease/urinary-tract-infections-in-adults/Pages/facts.aspx. Accessed March 11, 2016.

[7] Centers for Disease Control and Prevention. Urinary tract infection. http://www.cdc.gov/getsmart/community/for-patients/common-illnesses/uti.html. Accessed March 11, 2016.

[8] Griebling TL. Urologic diseases in America project: trends in resource use for urinary tract infections in women. J Urol. 2005;173(4):1281-7.

[9] Ibid.

[10] Centers for Disease Control and Prevention. Urinary tract infection. http://www.cdc.gov/getsmart/community/for-patients/common-illnesses/uti.html. Accessed March 11, 2016.

[11] Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol. 2015;13(5):269-284.

[12] Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-120.

[13] Zalmanovici Trestioreanu A, Green H, Paul M, et al. Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database Syst Rev. 2010;10:CD007182.

[14] Stein GE. Comparison of single-dose fosfomycin and a 7-day course of nitrofurantoin in female patients with uncomplicated urinary tract infection. Clin Ther. 1999;21(11):1864-72.

[15] Rafalsky V, Andreeva I, Rjabkova E. Quinolones for uncomplicated acute cystitis in women. Cochrane Database Syst Rev. 2006;3:CD003597.

[16] Milo G, Katchman EA, Paul M, et al. Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane Database Syst Rev. 2005;2:CD004682.

[17] Lutters M, Vogt-Ferrier NB. Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women. Cochrane Database Syst Rev. 2008;3:CD001535.

[18] Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.

[19] Zalmanovici Trestioreanu A, Lador A, Sauerbrun-Cutler MT, Leibovici L. Antibiotics for asymptomatic bacteriuria. Cochrane Database Syst Rev. 2015;4:CD009534.

[20] Drug profile: Nitrofurantoin. WorstPills.org. /monographs/view/268. Accessed March 11, 2016.

[21] Often-Misused Fluoroquinolone Antibiotics Pose Serious Risks. Worst Pills, Best Pills News. October 2015. /newsletters/view/993. Accessed March 11, 2016.

[22] National Institutes of Health. DailyMed. Nitrofurantoin macrocrystals label (updated July 2015). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e6adddba-2477-4cfb-a6b9-2651643e05ac. Accessed March 11, 2016.

[23] National Institutes of Health. DailyMed. Bactrim DS label (updated December 2014). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f59d0c04-9c66-4d53-a0e1-cb55570deb62. Accessed March 11, 2016.

[24] National Institutes of Health. DailyMed. Levaquin label (updated November 2015). http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a1f01e8e-97e9-11de-b91d-553856d89593#S1.13. Accessed February 16, 2016.

[25] Fluoroquinolones Linked to Life-Threatening Blood Vessel Complications. Worst Pills, Best Pills News. April 2016. /newsletters/view/1029. Accessed April 11, 2016.

[26] National Institutes of Health. Urinary tract infection in women — self-care: Preventing future urinary tract infections. https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000391.htm. Accessed March 11, 2016.

[27] Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2012;10:CD001321.

[28] Foxman B, Cronenwett AE, Spino C, Berger MB, Morgan DM. Cranberry juice capsules and urinary tract infection after surgery: Results of a randomized trial. Am J Obstet Gynecol. 2015;213(2):194.e1-8.

[29] Ibid.