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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. For example, 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. Of major 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.
Resistance to antibiotics is most often observed in the hospital setting. Unfortunately, there has
been a major worldwide increase within the community in E. coli resistance to standard
antibiotics used for UTIs. A major study, the ECO.SENS Project, has been designed to
investigate resistant UTI bacteria in 17 European countries. In a 2003 report, 42% of E. coli were
resistant to one or more of the 12 antibiotics investigated. Resistance was highest to ampicillin
(29.8%). Resistance to TMP-SMX (Bactrim, Cotrim, Septra) was 14.1%. (E. coli is the most
common bacteria in urinary tract infections.) Resistance to other common UTI antibiotics,
including mecillinam, cefadroxil, nitrofurantoin, fosfomycin, gentamicin, and ciprofloxacin still
averaged under 3%. 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 European study, for example, resistance rates were highest in Portugal and
Spain and lowest in the Nordic countries and Austria.

Specific Antibiotics Used for Most UTIs

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 amoxicillin, a penicillin antibiotic, but it is now ineffective against E. coli
bacteria in up to 25% of cases. A combination of amoxicillin-clavulanate

(Augmentin) is sometimes given for drug-resistant infections. Amoxicillin or

Augmentin may be useful for UTIs caused by gram-positive organisms, including
Enterococcus species and S. saprophyticus.
Cephalosporins. Antibiotics known 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:

First generation includes cephalexin (Keflex), cefadroxil (Duricef, Ultracef),

and cephradine (Velosef).
Second generation include cefaclor (Ceclor), cefuroxime (Ceftin), cefprozil
(Cefzil), and loracarbef (Lorabid).
Third generation include cefpodoxime (Vantin), cefdinir (Omnicef) cefditoren
(Sprectracef), cefixime (Suprax), and ceftibuten (Cedex). Ceftriaxone
(Rocephin) is an injected cephalosporin. These are effective against a wide
range of gram-negative bacteria.

Other Beta-Lactam Agents. Other beta-lactam antibiotics have been developed. For
example, pivmecillinam (a form of mecillinam), is commonly used in Europe 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-sulfamethoxazole, commonly called TMP-SMX (Bactrim, Cotrim,
Septra). A one-day course is somewhat less effective but poses a lower risk for side
effects. Longer courses (7 to 10 days)work no betterthan the three-day course and
have a higher rate of side effects. TMP-SMX should not be used in patients whose
infections occurred after dental work or in patients allergic to sulfa drugs. Allergic
reactions can be very serious. Trimethoprim (Proloprim, Trimpex) is sometimes used
alone in those allergic to sulfa drugs. TMP-SMX can interfere with the effectiveness
of oral contraceptives. High rates of bacterial resistance to TMP-SMX are being
observed in parts of the US, such as the Southeast, Southwest, and southern
California. Still, even when regional rates approach 30%, cure rates with TMP-SMX
reach 80% to 85%.
Fluoroquinolones (Quinolones)
Fluoroquinolones (also simply called quinolones) interfere with the bacteria's
genetic material so they cannot reproduce. They are the standard alternatives to
TMP-SMX. Examples of quinolones include ofloxacin (Floxacin), ciprofloxacin (Cipro),
norfloxacin (Noroxin), levofloxacin (Levaquin), gatifloxacin (Tequin), and sparfloxacin

(Zagam). These antibiotics are effective against a wide range of organisms but are
expensive 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 TMP-SMX.

In communities where there are high rates of bacteria resistant to TMP-SMX.

In elderly patients. A 2001 study of older women with UTIs (mean age 80),
about half of whom were living in nursing homes, found that 96% responded
to ciprofloxacin, compared with 87% to TMP-SMX.

Pregnant women should not take fluoroquinolone antibiotics. They also

have more adverse effects in children than other antibiotics and should not
be the first-line option in most situations.
Antibiotics Used Specifically for UTIs
Nitrofurantoin. Nitrofurantoin (Furadantin, Macrodantin) is a relatively
inexpensive antibiotic that is used specifically for urinary tract infections.
It is an effective alternative to TMP-SMX or a quinolone. Unlike many of
the other drugs, however, it must be given seven to 10 days, even in cases of
simple cystitis. (Shorter course treatments are being investigated.) It is not
useful for treating kidney infections. Nitrofurantoin frequently causes
stomach upset and interacts with many drugs. Other chronic or serious
medical conditions may also affect its use. It should not be used in
pregnant women within a week or two of delivery, in nursing mothers, or
in those with kidney disease.
Fosfomycin. The antibiotic fosfomycin (Monurol), which comes in an
orange-flavored, soluble powder, is proving to be another good alternative.
It can be an effective one-dose treatment for many women, including those
who are pregnant. To date, bacterial resistance rates to this antibiotic are
very low.
Tetracyclines
Tetracyclines inhibit bacterial growth. They include doxycycline,
tetracycline, and minocycline. Long-term treatment with tetracycline or
doxycycline may be used for infections that are caused by Mycoplasma or
Chlamydia. Tetracyclines have unique side effects among antibiotics,
including skin reactions to sunlight, possible burning in the throat, and
tooth discoloration.

Aminoglycosides
Aminoglycosides (gentamicin, kanamycin, tobramycin, amikacin) are
given by injection for very serious bacterial infections. They can be given
only in combination with other antibiotics. Gentamicin is the most
commonly used aminoglycoside for serious UTIs. They can have very
serious side effects, including damage to hearing, sense of balance, and
kidneys. Treatment for Uncomplicated UTIs
Studies are now reporting that uncomplicated UTIs in low-risk women can often be successfully
treated over the phone. In such cases, a health professional, usually a nurse, provides the patients
with three-day antibiotic regimens without even requiring an office urine test. This course is now
recommended only for women at low risk 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 55 years old; all other patients need to see a doctor for evaluation.
Antibiotic Regimen. Oral antibiotic treatment cures 94% 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 three-day course of trimethoprim-sulfamethoxazole, commonly

called TMP-SMX (Bactrim, Cotrim, Septra). A single oral dose of TMP-SMX is
sometimes prescribed in mild cases, but cure rates are generally lower (87%) than with
the three-day regimens. (Longer-term therapy, given for seven to 10 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 fluoroquinolone, such as ciprofloxacin (Cipro), is usually the
second choice. In fact, it is often the first choice where there are the high rates of
bacterial resistant to TMP-SMX. Fluoroquinolones can also be given in a three-day
course. Pregnant women should not take these drugs.

Nitrofurantoin (Furadantin, Macrodantin) is a third option. Thisdrug must be given for

longer than three days.

Fosfomycin (Monurol) is not as effective as other antibioticsbut may be used during

pregnancy. Resistance rates to this drug are also very low.

After a week 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 weeks in about 10% of women. Relapse is treated similarly to a first infection but
the antibiotics are continued for at least two weeks. (Relapsing infections may be due to

structural abnormalities, abscesses, or other problems that may require surgery, and such
conditions should be ruled out.)

Antibiotic Treatment for Recurrent Infections

Preventive antibiotics may be required for women who experience two or more symptomatic
UTIs within six 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 life-style measures to prevent
recurrences.
Intermittent Self Treatment. Many, if not most, women with recurrent UTIs can effectively self
treat recurrent UTIs without going to a doctor. In general, she takes the following steps:

As soon as the patient develops symptoms, she takes the antibiotic. Infections that occur
less than twice a year are usually treated as if they were an initial attack, with single-dose
or three-day antibiotic regimens.
At that time, she also performs a clean-catch 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 48 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.

Women who are not good candidates for self-treatment are those who are unable to diagnose
themselves or women with impaired immune systems, previous kidney infections, structural
abnormalities of the urinary tract, or a history of infection with antibiotic-resistant bacteria.
Postcoital Antibiotics. If recurrent infections are clearly related to sexual activity and episodes
recur more than two times within a six-month period, a single preventive dose taken immediately
after intercourse has proven to be very effective. Antibiotics in such cases include TMP-SMX,
nitrofurantoin, cephalexin, or a fluoroquinolone (such as ciprofloxacin). (Fluoroquinolones are
not appropriate during pregnancy.)
Continuous Preventive Antibiotics (Prophylaxis). Continuous preventive (prophylactic)
antibiotics are an option for some women who do not respond to other measures. With this
approach, low-dose antibiotics are taken continuously for six months or longer.
Typical prophylactic regimens include one dose of nitrofurantoin (50 mg), 1/2 tablet of TMPSMX, or cephalexin (250 mg) daily. Taking the antibiotic at bedtime may be most effective.
Studies suggest that continuous prophylactic antibiotics reduces recurrences by up to 95% and
may prevent kidney infection.

Adverse effects mostly include gastrointestinal problems and yeast infections. (Taking probiotic
supplements or eating yogurt may help prevent yeast infections.) Although there is concern that
continuous risk increases the risk for bacteria that are resistant to the antibiotics, studies to date
have not reported any significant risk even up to five years of use.

Antibiotics for Kidney Infections (Pyelonephritis)

Treating Uncomplicated Kidney Infections. Patients with uncomplicated kidney infections
(pyelonephritis) may be treated at home with oral antibiotics. Such patients are healthy and non
pregnant. They typically are experiencing fever, chills, and flank pain. However, they are not
nauseous or vomiting and show no symptoms or signs of kidney involvement or complicated
infection.
The standard treatment for uncomplicated pyelonephritis is a 14-day course of oral antibiotics,
usually trimethoprim-sulfamethoxazole (TMP-SMX) or a fluoroquinolone. Sometimes patients
with uncomplicated pyelonephritis are first given an antibiotic injection, if indicated.
Oral amoxicillin or amoxicillin-clavulanate (Augmentin) may be prescribed for women with
bacteria that do not respond to standard regimens (e.g., gram-positive organisms, including
Enterococcus species and S. saprophyticus).
A urine culture is may be obtained within one week of completion of therapy and again four
weeks later.
Treating Moderate to Severe Kidney Infections. Patients with moderate to severe acute kidney
infection and those with severe symptoms or other complications may need to be hospitalized. In
such cases, antibiotics (ceftriaxone 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 24 to
48 hours. One study reported that oral cefixime 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 weeks; treatment for longer
than this has no additional benefit.
If fever and back pain persist after 72 hours of antibiotic administration, the doctor will usually
order imaging tests to see if abscesses, obstructions, or other abnormalities are present.
Treating Chronic Kidney Infections. Patients with chronic pyelonephritis are often treated with
long-term antibiotics, even during periods when they have no symptoms.

Treatments for Interstitial Cystitis

There are two approved treatments for interstitial cystitis: Pentosan polysulfate (Elmiron), and
dimethyl sulfoxide (DMSO). Patients generally prefer Elmiron because it can be taken by mouth.
A DMSO solution is instilled into the bladder through a catheter. Elmiron is a type of blood
thinner that helps to coat the bladder lining and prevent infections. It may take several months
before it has an effect on symptoms, but its benefits increase the longer it is used.

Doctors sometimes also prescribe other types of medications to help interstitial

cystitis symptoms. These drugs include antihistamines such as hydroxyzine
(Atarax), and low doses of the tricyclic antidepressant amitriptyline
(Elavil). Drugs that reduce bladder spasms (hyoscine, oxybutynin) are also
sometimes used. Some doctors think that interstitial cystitis may be related
to immune disorders. Researchers are investigating various drugs that
block immune and inflammatory responses. Treatments for Specific
Populations
Treating the Pregnant Woman. Pregnant women should be screened for UTIs, since they are at
high risk for UTIs and their complications. The antibiotics used during pregnancy are
amoxicillin, ampicillin, nitrofurantoin, or an oral cephalosporin. Fosfomycin (Monurol) is not as
effective as others but may be used during pregnancy. Resistance rates to this drug are also very
low. They should not take fluoroquinolones.
Pregnant women with even asymptomatic bacteriuria (evidence of infection but no symptoms)
have a 30% risk 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 take low-dose
nitrofurantoin. For an uncomplicated UTI, pregnant women may need longer-term antibiotics
(seven to 10) for urinary tract infections.
Women with pyelonephritis have, to date, been hospitalized for treatment. One 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 injection of ceftriaxone in the emergency room,
observed for a few hours, and then administered a second injection. After this, they were sent
home with a prescription for an oral antibiotic.
Treating Women with Diabetes. Women with diabetes have more frequent and more severe UTIs
than women without the disease. Many experts recommend that patient with diabetes and UTI,
even an uncomplicated infection, be treated with antibiotics for seven to 14 days. People 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 2003 study indicated that treating this
condition had little value in these women and did not prevent complications.
Treating Urethritis in Men. Urethritis in men has typically been treated with a seven-day regimen
of doxycycline. Some research is showing that a single dose of azithromycin may be just as
effective while causing fewer side effects. One-dose treatment also improves compliance, so cure
rates may even be better than with a long-term regimen. Of 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 mask the symptoms of an accompanying sexually transmitted disease, such as
gonorrhea. Tests for such diseases should be conducted if urethritis is diagnosed.

Treating Children with UTIs. Children with UTIs are generally treated with TMP-SMX or
cephalexin (Keflex). The optimal duration is unclear. In one major 2003 analysis, a two- to fourday treatment was as effective as seven to 14 days. If initial therapy fails, then one injection of
ceftriaxone or 10 days of intravenous gentamicin nearly always cure the infection. Children can
be treated effectively for acute pyelonephritis with oral cefixime (Suprax) or a short course (two
to four days) of an intravenous (IV) antibiotic (typically gentamicin given in one daily dose). The
IV antibiotic is then followed by an oral antibiotic.
Either long-term antibiotics or surgery to correct vesicoureteral reflux (VUR) are options to
prevent infections in children (particularly girls) with VUR. It is unclear if either approach is any
more effective than the other. Studies are finding no significant difference in kidney 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
2002 study reported that continuous antibiotics prevented infection in 72% of girls and all of
boys over more than two years. Antibiotics were stopped after about four years on average, and
42% experienced UTIs or kidney infections afterward. The use of long-term antibiotics in VUR
is controversial, however. There have been few well-conducted studies, and in one study, there
was no difference in risk for UTI or kidney damage between patients who were taking 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 Catheter-Induced Urinary Tract Infections

Preventing Catheter-Induced Infections
Catheter-induced urinary tract infections are very common and preventive measures
are extremely important. Catheters should not be used unless absolutely necessary,
and they should be removed as soon as possible. Reducing the risk for infections
during long-term catheter use, however, remains problematic.
Catheter Coatings. Catheter coatings, such as silver nitrate, antibiotics, and other
substances, are being tested and are showing some benefits, but the problem is still
not resolved. One promising catheter (LoFric) uses a so-called hydrophilic coating
consisting of PVP (polyvinyl pyrrolidone) and salt. It attracts water to the catheter
surface, putting up a water barrier to reduce friction. In a 2003 study, it was
associated with significantly fewer UTIs.
Intermittent Use of Catheters. If a catheter is required for long periods, it is best to
use it intermittently if possible (as opposed to an indwelling catheter). Some doctors
recommend replacing it every two weeks to reduce the risk of infection and
irrigating the bladder with antibiotics between replacements.
Daily Hygiene. A 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:

Drink plenty of fluids, including three glasses of cranberry juice a day.

The catheter tube should be free of any knots or kinks.

Clean the catheter and the area around the urethra with soap and water daily
and after each bowel movement. (Women should be sure to clean front to
back.)

Wash hands before touching the catheter or surrounding area.

Never disconnect the catheter from the drainage bag without careful
instructions from a health professional on strict methods for preventing
infection.

Keep the drainage bag off the floor.

Stabilize the bag against the leg using tape or some other system.

Antibiotics for Catheter-Induced Infections

Patients using catheters who develop UTIs with symptoms should be treated for
each episode with antibiotics and the catheter should be removed, if possible. A
major problem in treating catheter-related UTIs is that the organisms involved are
constantly changing. Because there are likely to be multiple species of bacteria,
experts generally recommend an antibiotic that is effective against a wide variety of
microorganisms. These medications include those in the fluoroquinolone group and
drug combinations such as ampicillin plus gentamicin or imipenem plus cilastatin.
Although high bacteria counts in the urine (bacteriuria) occur in most catheterized
patients, administering antibiotics to prevent a UTI is rarely recommended. Many
catheterized patients do not develop symptomatic urinary tract infections even with
high bacteria counts. If bacteriuria occurs without symptoms, antibiotic therapy has
little benefit if the catheter is to remain in place for a long period.

Catheterization is accomplished by inserting a catheter (a hollow tube, often with and inflatable 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 kept empty (decompressed) and urinary flow assured.
Catheterization in males is slightly more difficult and uncomfortable than in females because of the
longer urethra.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation

HealthCare Commission (www.urac.org).