The infectious disease society of America had new treatment guidelines this year on UTIs.
For acute uncomplicated cystitis( healthy women, ambulatory with no history of anatomical or functional abnormality of urinary tract):
1. The primary goal should be to ameliorate symptoms.
2. New guidelines take into effect not only the efficacy of the drug, but current resistant patterns as well.
3. Nitrofurantoin, TMP-SMX, fosfomycin and pivmecillinam( not in US) are first line agents for cystitis even with resistant patterns with first two and less efficacy with the latter two.
4. Fluroquinolones have now been assigned as second line agents for cystitis but they are the drug of choice for emperic treatment of pyelonephritis.
5. Beta lactams are also second line agents.
Nitrofurantoin is not as effective in certain cases. TMP-SMX has higher resistant patterns now. Fosfomycin is given as a 3gm sachet in a single dose and has 91% efficacy based on a single trial but less effective than TMP-SMX or fluoroquinolones. Unfortunately, many labs don't test for resistant patterns against this agent. Pivmecillinam is not available in the US.
Complicated UTI is men, women or children with structural, functional abnormalities in urinary tract. Male gender, obstruction, neurogenic bladder, DM, renal failure and transplantation increase the risk.
For a review on these changes, please see NEJM article earlier this year.
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