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Acute Uncomplicated UTIs in Adults: Rapid Evidence Review

This is an updated version of the article that appeared in print.

Note: In April 2024, the U.S. Food and Drug Administration approved Pivya (pivmecillinam) tablets for the treatment of female adults with uncomplicated urinary tract infections (UTIs) caused by susceptible isolates of Escherichia coli, Proteus mirabilis, and Staphylococcus saprophyticus. This article has been revised to reflect the U.S. Food and Drug Administration's approval.

This is a corrected version of the article that appeared in print.

Peter K. Kurotschka, MD
Ildikó Gágyor, MD
Mark H. Ebell, MD, MS

American Family Physician. 2024;109(2):167-174.

Author disclosure: No relevant financial relationships.

Patient information: A related handout on uncomplicated urinary tract infections is available.

An acute uncomplicated urinary tract infection (UTI) is a bacterial infection of the lower urinary tract with no sign of systemic illness or pyelonephritis in a noncatheterized, nonpregnant adult with no urologic abnormalities or immunocompromise. In women, a self-diagnosis of a UTI with the presence of typical symptoms (e.g., frequency, urgency, dysuria/burning sensation, nocturia, suprapubic pain), without vaginal discharge, is accurate enough to diagnose an uncomplicated UTI without further testing. Urine culture and susceptibility testing should be reserved for women with recurrent infection, treatment failure, history of resistant isolates, or atypical presentation to make a definitive diagnosis and guide antibiotic selection. First-line antibiotics include nitrofurantoin for five days, fosfomycin in a single dose, trimethoprim for three days, or trimethoprim/sulfamethoxazole for three days. Symptomatic treatment with nonsteroidal anti-inflammatory drugs and delayed antibiotics may be considered because the risk of complications is low. Increased fluids, intake of cranberry products, and methenamine hippurate can prevent recurrent infections. Antibiotic prophylaxis is also effective in preventing recurrence but has a risk of adverse effects and antimicrobial resistance. Men with lower UTI symptoms should always receive antibiotics, with urine culture and susceptibility results guiding the antibiotic choice. Clinicians should also consider the possibility of urethritis and prostatitis in men with UTI symptoms. First-line antibiotics for men with uncomplicated UTI include trimethoprim, trimethoprim/sulfamethoxazole, and nitrofurantoin for seven days. Uncomplicated UTIs in nonfrail women and men 65 years and older with no relevant comorbidities also necessitate a urine culture with susceptibility testing to adjust the antibiotic choice after initial empiric treatment; first-line antibiotics and treatment durations do not differ from those recommended for younger adults.

This article provides a rapid evidence review of the best available patient-oriented evidence for acute uncomplicated urinary tract infection (UTI) in adults. An uncomplicated UTI is a bacterial infection of the lower urinary tract in a noncatheterized, nonpregnant adult without urologic abnormalities, immunocompromise, or signs of systemic illness or pyelonephritis. More than 80% of UTIs occur in women; therefore, unless specified, the recommendations in this article are for adult women younger than 65 years. Recommendations for uncomplicated UTIs in other populations, such as men and women and men 65 years or older, are reviewed briefly. Nonbinary and transgender people should be evaluated and treated according to their current urogenital anatomy.

WHAT'S NEW ON THIS TOPIC

Urinary Tract Infections
In U.S. outpatients, the resistance of common uropathogens to beta-lactam antibiotics, trimethoprim/sulfamethoxazole, and fluoroquinolones is greater than 55%, 22%, and 21%, respectively.
Recent European and UK guidelines do not recommend trimethoprim/sulfamethoxazole due to concerns about adverse effects (rare but severe skin and neurologic manifestations), allergy, and increasing resistance in many communities.
Relapse within two weeks or recurrent urinary tract infections are equally likely in women initially treated with or without antibiotics.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comment
Diagnose an uncomplicated UTI in women who believe they have a UTI and report typical acute lower urinary symptoms without vaginal discharge.14,15,17–19 C Meta-analyses of observational studies
Perform a urine culture with susceptibility testing in women with recurrent UTIs, treatment failure with first-choice antibiotics, history of resistant urinary isolates, atypical presentation, or age 65 years or older and in men to guide the antibiotic choice.5,6,24,25 C Consensus, expert opinion
Women with no signs of pyelonephritis or complicated infection who do not want to take antibiotics can be prescribed a backup antibiotic to be filled if symptoms do not improve within 48 to 72 hours or worsen at any time. Patients should be advised to drink at least 1.5 L of fluids daily and use acetaminophen or nonsteroidal anti-inflammatory drugs for symptom relief.6,23,26 C Consensus, expert opinion
First-line antibiotics for uncomplicated UTI in women include fosfomycin, single 3-g dose; extended-release nitrofurantoin, 100 mg twice daily for five days; trimethoprim, 200 mg twice daily for three days; trimethoprim/sulfamethoxazole, 160/800 mg twice daily for three days; or pivmecillinam, 400 mg three times daily for three days.5,6,23,26,33–35 A RCTs, meta-analyses, and evidence-based guidelines
Adequate fluid intake (at least 1.5 L per day) and cranberry products are effective in preventing recurrent UTI in women.41,43 B Meta-analyses of RCTs
Methenamine hippurate is effective in preventing recurrent UTI.45 B One high-quality RCT
In afebrile men with uncomplicated UTI, a seven-day course of an oral antibiotic is as effective as a longer course.55 B One high-quality RCT

RCT = randomized controlled trial; UTI = urinary tract infection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

PETER K. KUROTSCHKA, MD, is a family physician and research associate in primary care in the Department of General Practice at the University Hospital Würzburg, Germany.

ILDIKÓ GÁGYOR, MD, is a family physician and professor in and chair of the Department of General Practice at the University Hospital Würzburg.

MARK H. EBELL, MD, MS, is a family physician and professor in the Department of Epidemiology at the University of Georgia College of Public Health, Athens.

Address correspondence to Peter K. Kurotschka, MD, University Hospital Würzburg: Universitätsklinikum Würzburg, Josef-Schneider-Str. 2, 97080 Würzburg, Bavaria, Germany (kurotschka_p@ukw.de). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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