Continuing Education Activity

Uncomplicated urinary tract infections (UTIs) are among the most common bacterial infections encountered in clinical practice. They primarily affect the lower urinary tract, including the bladder and associated structures. Unlike complicated UTIs, uncomplicated cases occur in otherwise healthy individuals without structural abnormalities in the urinary tract or significant comorbidities. Although some cases may resolve spontaneously, many patients seek therapy to relieve symptoms and prevent potential complications. Symptoms include urinary frequency, urgency, dysuria, and suprapubic discomfort.

Prompt and accurate diagnosis of uncomplicated UTIs is crucial for timely and appropriate management. Diagnosis relies on clinical history, urinalysis, and urine culture, with proper specimen collection being essential. Treatment strategies typically involve the use of first-line therapies, including nitrofurantoin, trimethoprim/sulfamethoxazole, trimethoprim alone, fosfomycin, cephalosporins, and pivmecillinam. Preventive strategies to reduce UTIs are crucial for alleviating the burden on healthcare resources. This activity reviews uncomplicated UTIs, focusing on their clinical presentation, diagnosis, and guideline-based treatment approaches. This activity also emphasizes the importance of interprofessional collaboration among healthcare providers in delivering coordinated and comprehensive care while improving outcomes for uncomplicated UTIs.

Objectives:

• Identify the clinical signs and symptoms of uncomplicated urinary tract infections in otherwise healthy patients.

• Implement appropriate diagnostic tests, including urinalysis and urine culture, for accurate diagnosis of uncomplicated urinary tract infections.

• Select the appropriate antibiotic regimen based on patient-specific factors and antibiotic susceptibility for uncomplicated urinary tract infections.

• Collaborate with the interprofessional healthcare team to ensure comprehensive care, including preventive strategies to reduce recurrent urinary tract infections.

Introduction

An uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. This condition occurs in patients without structural abnormalities of the urinary tract or comorbidities such as diabetes, an immunocompromised state, recent urologic surgery, or pregnancy. An uncomplicated UTI is also referred to as cystitis or a lower tract UTI.

Bacteriuria or pyuria without symptoms does not constitute a UTI. Typical UTI symptoms include urinary frequency, urgency, suprapubic discomfort, and dysuria. While UTIs are very common in women, they are rare in circumcised males. When UTIs occur in circumcised males, they are generally considered complicated UTIs. Please see StatPearls' companion resource, "Complicated Urinary Tract Infections," for more information.

Many uncomplicated UTIs resolve spontaneously without treatment, but patients often seek therapy for symptom relief. Treatment aims to prevent the infection from spreading to the kidneys or progressing to an upper tract disorder such as pyelonephritis, which can damage delicate nephron structures and eventually lead to complications such as hypertension.[1][2][3]

UTI diagnosis is based on clinical history and urinalysis, with confirmation through a urine culture. Proper urine sample collection is crucial for accurate evaluation and culture. Complicated and recurrent UTIs are discussed in separate articles. Please see StatPearls' companion resources, "Complicated Urinary Tract Infections" and "Recurrent Urinary Tract Infections," for more information.

Etiology

Pathogenic bacteria ascend from the perineum and rectum to the periurethral area, increasing the risk of UTIs in women. Additionally, women have shorter urethras than men, further enhancing their susceptibility. Blood-borne bacteria rarely cause uncomplicated UTIs.

Escherichia coli is responsible for the majority of UTIs, followed by Klebsiella. Other important organisms include Proteus, Enterobacter, and Enterococcus.[4][5]

A significant risk factor for UTIs is the use of a urinary catheter, as well as urethral manipulation. UTIs are also common after kidney transplants, with immunosuppressive drugs and vesicoureteral reflux being key contributing factors. Additional risk factors include the use of antibiotics, which can lead to the development of resistant bacterial strains, and diabetes mellitus.

Other risk factors include:

• Abnormal urination (eg, incomplete emptying and neurogenic bladder)
• Abnormal urinary tract anatomy or function
• Antibiotic use and increasing bacterial resistance
• Cystocele
• Dehydration
• Diabetes
• Diarrhea
• First UTI before age 15
• Frequent pelvic examinations
• Incomplete bladder emptying
• Immune system suppression or inadequacy
• Irritable bowel syndrome 
• Menopause
• Mother with a history of multiple UTIs
• New or multiple sexual partners
• Poor personal hygiene
• Pregnancy
• Sexual intercourse
• Urinary tract calculi
• Use of spermicides and diaphragms [6][7]

Please see StatPearls' companion resources, "Cystitis" and "Acute Cystitis," for more information.

Epidemiology

UTIs occur at least 4 times more frequently in females than males. The following are key statistics regarding UTIs:

• Approximately 40% of women in the United States will develop a UTI during their lifetime.
• Approximately 10% of women experience a UTI annually.
• Recurrences are common, with nearly 50% of patients experiencing a second infection within a year.
• UTIs are most common in women between the ages of 16 and 35.[8][9]

Pathophysiology

An uncomplicated UTI typically involves only the bladder. The majority of organisms causing UTIs are enteric coliforms, which normally inhabit the periurethral vaginal introitus. When these organisms ascend the urethra into the bladder, they invade the bladder mucosal wall, triggering an inflammatory reaction known as cystitis. Sexual intercourse is a common cause of UTIs, as it facilitates the passage and introduction of bacteria into the bladder.[10]

Urine has natural antimicrobial properties. Factors that make it unfavorable for bacterial growth include a pH of less than 5, high urea levels, hyperosmolality, and the presence of organic acids, proteins, and nitrites.[11][12] Urinary proteins, such as Tamm-Horsfall glycoproteins, nitrites, and urea, all act as bacterial growth inhibitors.[11][12][13][14][15] Frequent urination and high urinary volumes also reduce the risk of UTIs. The bladder wall is lined with a layer of mucus that serves as a mechanical barrier to bacterial infiltration and invasion. Any defect or injury to this mucosal layer is considered a predisposing factor for UTIs and recurrent infections.[16] 

Urothelial cells also have a key role in protecting the bladder from infection by producing antimicrobial peptides and proinflammatory cytokines, such as interleukins (ILs)-1, IL-6, and IL-8.[17] They can encapsulate bacteria in fusiform vesicles, and when heavily infected, the superficial urothelial layer may shed, significantly reducing bacterial load.[17][18] In premenopausal women, high concentrations of lactobacilli in the vagina and an acidic vaginal pH help prevent colonization by uropathogens. However, antibiotic use can disrupt this protective effect.[19]

Bacteria that cause UTIs tend to have adhesins on their surface, allowing organisms to attach to the urothelial mucosal surface.[20] Pathogenic bacteria also develop mechanisms to survive hyperosmolality, with many able to break down urea into alkaline ammonia, thereby increasing urinary pH.[17] Additionally, the short female urethra facilitates easier invasion of the bladder and lower urinary tract by uropathogens. Please see StatPearls' companion resource, "Complicated Urinary Tract Infections," for more information.

Glycosuria can increase the risk of UTIs in diabetics, and recurrent infections may delay the recovery of the superficial urothelium and protective mucus layer.[21] Medications that induce glycosuria for diabetes control, such as empagliflozin and similar agents, may also contribute to this effect. However, real-world studies suggest that this effect is relatively minimal.[22][23][24]

History and Physical

Symptoms of uncomplicated UTIs typically include dysuria (painful urination), urinary frequency, hesitancy (difficulty starting the urine stream), urgency (sudden onset of the need to urinate), suprapubic pain or discomfort, bladder spasms, and hematuria (blood in the urine).[25] Generally, patients with uncomplicated UTIs do not experience fever, chills, nausea, vomiting, or back/flank pain, which are more indicative of renal involvement or pyelonephritis. Patients with neurological conditions, such as multiple sclerosis, may present atypically, potentially experiencing an acute exacerbation of neurological symptoms. Please see StatPearls' companion resource, "Cystitis," for more information.

Clinical symptoms can overlap, making it challenging to distinguish an uncomplicated UTI from pyelonephritis or other serious infections. When uncertain, it is typically best to treat aggressively for potential upper urinary tract involvement. Additionally, information regarding prior antibiotic use and previous UTIs should be obtained.

Physical examination findings are usually negative in patients with an uncomplicated UTI, although suprapubic tenderness may be present in 10% to 20% of cases. Patients with recurrent UTIs, unexplained incontinence, or suspected organ prolapse should undergo a pelvic examination. Please see StatPearls' companion resource, "Cystitis," for more information. 

A UTI diagnosis is based on a combination of signs, symptoms, and urinalysis results, which is confirmed with a urine culture. Clinicians should be cautious when diagnosing a UTI based solely on urinalysis or culture results in asymptomatic patients. In the absence of clinical signs or symptoms, the presence of pyuria or bacteriuria does not necessarily indicate a UTI.

Odoriferous or cloudy urine is often associated with UTIs and bacteriuria. However, these findings alone do not warrant antibiotic treatment unless the patient shows additional signs or symptoms.[26] In such cases, increased hydration and a thorough review of contributing dietary and drug factors are recommended.

Unusual urinary cloudiness (turbidity) and odor can be influenced by several factors, including:

• Amorphous phosphates
• Foods (see below)
• Hormonal changes (eg, pregnancy)
• Hydration status
• Liver failure 
• Medications (eg, sulfonylurea)
• Renal failure
• Sexually transmitted infections
• Trimethylaminuria
• Vaginal infections
• Vitamins
• Voiding dysfunction unrelated to infection

Foods that can cause urinary odor include:

• Asparagus
• Brussels sprouts
• Fish (eg, salmon)
• Garlic
• Onions
• Spices
• Sulfur-containing foods

Specific Patient Populations

Older and/or frail patients: In older patients, symptoms may include changes in mental status or behavior, such as unexplained lethargy, disorganized speech, or altered perception.[26][27] The most reliable indicators in these patients include changes in mental status, abnormal urinalysis (pyuria and bacteriuria), and dysuria.[26] Additional symptoms may include nocturia, incontinence, or a general sense of not feeling well without specific urinary symptoms.[28]

Spinal cord–injured patients: Patients with spinal cord injuries and paralysis may present with the following symptoms:

• Autonomic dysreflexia, which presents with severe hypertension and headache in patients with spinal cord injuries at T-6 or higher. Please see StatPearls' companion resource, "Autonomic Dysreflexia," for more information.
• Chills
• Cloudy or foul-smelling urine 
• Fever
• Increased or newly developed spasticity
• Unexplained fatigue or changes in mental status

Patients with permanent indwelling Foley catheters or suprapubic tubes: Patients with permanent indwelling Foley catheters or suprapubic tubes may exhibit vague signs and symptoms, such as an elevated leukocyte count and low-grade fever. Most patients with catheters will show pyuria and high urinary bacterial colony counts; however, this does not indicate an actual UTI. Treatment should only be considered if there are systemic signs or symptoms, such as pain, spasms, fever, hematuria, or other unexplained bladder abnormalities.

Evaluation

Urine Specimen Collection

A properly collected, clean urine specimen is essential for an accurate work-up. Patients should wash their hands before collecting a sample. Midstream voided clean catch specimens are the most accurate and are preferred in nonobese women and men, provided the patient follows the correct technique. However, most obese women may struggle to obtain a clean, uncontaminated specimen. The presence of epithelial cells in the urinalysis indicates that the sample was exposed to the genital skin surface and did not come directly from the urethra. Obtaining a sample with minimal epithelial cells may require urethral catheterization. The risk of a UTI in uninfected women from a straight urethral catheterization is approximately 1%.

Men should wipe the glans penis, initiate the urine stream to clean the urethra, and then obtain a midstream sample. In young children and patients with spinal cord injuries, suprapubic aspiration may be required to collect an adequate urine specimen. The Foley should be changed in patients with catheters, and the specimen should be collected from the new catheter. A urine culture or urinalysis should never be performed from a sample taken directly from a urinary drainage bag. If necessary, the new Foley catheter should be clamped for a few minutes to allow enough urine to be collected for an adequate sample.

Urine specimens should be sent to the laboratory immediately or refrigerated, as bacteria proliferate when left at room temperature, leading to an overestimation of bacterial count and severity.[29][30]

Urinalysis

A UTI diagnosis should not be based solely on visual inspection of the urine. Cloudy urine can be aseptic, with turbidity potentially caused by protein or calcium phosphate debris rather than an infection. Conversely, crystal-clear urine can still be grossly infected. All urine samples should undergo dipstick testing, which can be performed in the clinic or at the bedside.

The most useful dipstick values for diagnosing a UTI are pH, nitrites, leukocyte esterase, and blood. Notably, in patients with UTI symptoms, a negative dipstick result does not rule out the infection, but positive findings can support the diagnosis. Additionally, microscopic urinalysis should be used to check for the presence of bacteria and/or white blood cells (WBCs) in the urine.

• Normal urine pH is slightly acidic, typically ranging from 5.5 to 7.5, with an overall normal range of 4.5 to 8.0. A urine pH of 8.5 to 9.0 may indicate the presence of a urea-splitting organism, such as Proteus, Klebsiella, or Ureaplasma urealyticum. An alkaline urine pH can also suggest the possibility of struvite kidney stones, also known as "infection stones." Please see StatPearls' companion resource, "Struvite and Triple Phosphate Renal Calculi," for more information.

• The nitrate test is the most accurate dipstick test for diagnosing a UTI because bacteria must be present in the urine to convert nitrates into nitrites. This conversion typically takes 6 hours, which is why urologists often request a first-morning urine sample for testing, particularly in males. The overall specificity of this test is greater than 90%.[31][32] This test directly confirms the presence of bacteria in the urine, which, by definition, indicates a UTI in symptomatic patients. However, some bacteria, such as Enterococcus, Pseudomonas, and Acinetobacter, do not convert nitrates to nitrites and are typically associated with complicated UTIs. The sensitivity of the nitrite urinary dipstick test ranges from 19% to 48%, while its specificity ranges from 92% to 100%.[33]

• Leukocyte esterase detects the presence of WBCs in the urine, which release leukocyte esterase, typically in response to bacteria. While leukocyte esterase can identify WBCs in the urine, this can also occur due to other causes, such as inflammatory disorders or vaginal infections. The reported sensitivity of the test ranges from 62% to 98%, with specificity between 55% and 96%. Despite these findings, leukocyte esterase is generally considered less reliable for diagnosing a UTI compared to nitrites. Please see StatPearls' companion resource, "Acute Cystitis," for more information.

• Hematuria can be a valuable finding, as bacterial infections of the transitional cell lining of the bladder often result in some bleeding. This helps differentiate a UTI from conditions like vaginitis and urethritis, which typically do not cause blood in the urine.

The predictive values of nitrite, leukocyte esterase, and blood on a dipstick for diagnosing a UTI have been evaluated. Urinary nitrites were found to be more significant than leukocyte esterase, with leukocyte esterase being more predictive than hematuria. Both positive nitrites and leukocyte esterase have demonstrated a high positive predictive value (PPV) of 85% and a negative predictive value (NPV) of 92%.[34] The combination of all three—nitrites, leukocyte esterase, and hematuria—has also proven diagnostically useful.[35] In addition, dysuria and new onset nocturia or frequency are associated with UTIs.

In many laboratories, the presence of nitrites or leukocyte esterase automatically triggers a microscopic evaluation of the urine for bacteria, WBCs, RBCs, and/or a urine culture. On microscopy, no bacteria should be visible in uninfected urine, so the presence of bacteria on a Gram-stained specimen under high-field microscopy is strongly correlated with bacteriuria and UTIs. A properly collected urine sample with more than 10 WBCs per high-power field (HPF) is considered abnormal and highly suggestive of a UTI in symptomatic patients. Clinicians should recognize that a UTI cannot be definitively diagnosed or excluded based solely on symptoms and dipstick testing.[36]

Urine Cultures

Although urine cultures are not absolutely required to detect uncomplicated UTIs, they are still recommended due to increasing antibiotic resistance patterns and their role in differentiating recurrent infections from relapsing ones. Cultures also help guide treatment if the patient does not respond to initial empiric first-line therapy. Urine cultures should always be obtained in cases of UTIs in men, individuals with diabetes mellitus, immunosuppressed patients, pregnant women, high-risk individuals, and those with recurrent UTIs. Please see StatPearls' companion resource, "Cystitis," for more information.

Classic teaching for diagnosing a UTI typically sets the threshold for culturing infected urine at more than 100,000 colony-forming units (CFUs) per milliliter (CFU/mL). However, recent literature and the American Urological Association Core Curriculum now indicate that a patient with symptoms and a urine culture showing more than 1000 CFU/mL should be diagnosed with a UTI. Approximately 20% to 40% of women with UTIs will have less than or equal to 10,000 CFU/mL on urine culture.[37] From a practical clinical perspective, the presence of a single organism in a symptomatic patient with more than or equal to 1000 CFU/mL is generally considered diagnostic for a UTI.[37] Please see StatPearls' companion resource, "Recurrent Urinary Tract Infections," for more information.

Urine cultures rarely provide immediate help in the Emergency Department, but they can significantly ease subsequent treatment for the follow-up clinician if patients do not respond to the initial antibiotic prescribed, especially in cases of recurrent UTIs.[38] While a single, uncomplicated UTI in an otherwise healthy individual may not always require a culture, the follow-up clinician has no objective data or evidence to guide therapy if the initial antibiotic treatment fails. As a result, many experts recommend that all patients treated for a presumed UTI should have a urine culture, which can be extremely valuable in various situations. A urine culture is recommended if a patient is sick enough to visit an urgent care center, physician's office, clinic, or hospital Emergency Department. It adds minimal cost to the overall visit while providing valuable clinical data, particularly if the patient fails to improve. Please see StatPearls' companion resource, "Cystitis," for more information.

Cystoscopy and urinary tract imaging are generally not routinely recommended for uncomplicated UTIs, as they are rarely helpful.[38] However, imaging may be useful in cases of relapsing infections to rule out stones and anatomical urinary tract abnormalities.

Treatment / Management

Asymptomatic bacteriuria is common and typically does not require treatment, except in pregnant women, immunosuppressed individuals, those who have had a transplant, those who recently underwent a urologic surgical procedure, or those who are preoperative for such surgery.

Management of Uncomplicated Urinary Tract Infections 

Guidance is based on recommendations from the Infectious Diseases Society of America, the European Society for Microbiology and Infectious Diseases, the European Association of Urology, and the American Urological Association.[39][40]

Antibiotic treatment duration has historically ranged from 3 days to 6 weeks. However, "mini-dose therapy," which involves just 3 days of treatment, has shown excellent cure rates. Treatment usually lasts between 3 and 14 days, with 5 to 7 days being the most common duration. Men should receive at least 7 days of antibiotic therapy.

E coli resistance to common antimicrobials varies across different regions. If the resistance rate to a particular antibiotic exceeds 50%, an alternative drug should be selected based on local bacterial sensitivity reports.

First-Line Agents for Uncomplicated Urinary Tract Infections

First-line agents for uncomplicated UTIs include nitrofurantoin, sulfamethoxazole/trimethoprim, trimethoprim alone, fosfomycin, and first-generation cephalosporins. Pivmecillinam is also considered a first-line option in cases where bacterial resistance to other primary agents is high.[25]

Nitrofurantoin: This is the preferred initial treatment for uncomplicated UTIs. However, it is bacteriostatic rather than bactericidal and must be used for 5 to 7 days.[41] This drug has multiple mechanisms of action that target bacteria, making resistance relatively uncommon. However, it is only effective in the lower urinary tract due to its poor tissue penetration and should not be used for presumed or possible pyelonephritis. Nitrofurantoin is the preferred first-line agent for low-dose, long-term prophylaxis in patients with recurrent UTIs. This drug is contraindicated in patients with an estimated glomerular filtration rate (GFR) of less than 45 mL/min. In men with uncomplicated UTIs, nitrofurantoin has a higher failure rate, which increases with age, likely due to prostatic involvement.[42] Please see StatPearls' companion resources, "Recurrent Urinary Tract Infections" and "Nitrofurantoin," for more information.

Sulfamethoxazole/trimethoprim: A combination of these drugs for 3 days is effective as mini-dose therapy; however, resistance rates are high in many areas. These drugs should be avoided if local bacterial resistance exceeds 20% or in patients with a sulfa allergy.[39][43][44] Sulfamethoxazole/trimethoprim is generally considered an alternative option for long-term prophylaxis in patients with recurrent UTIs. Trimethoprim alone may be used in patients with sulfa allergies. Please see StatPearls' companion resource, "Trimethoprim Sulfamethoxazole," for more information.

Fosfomycin: This drug has been approved by the US Food and Drug Administration (FDA) as a single-dose therapy for uncomplicated UTIs.[25][45] Fosfomycin may be effective in cases of significant resistance to other antimicrobials.[46] A single dose maintains therapeutic urinary concentrations for 2 to 4 days and is comparable to a 7- to 10-day course with other agents.[25][45][47] Adjunctive therapy with phenazopyridine for several days may help provide additional symptomatic relief.[48]

First-generation cephalosporins: These are effective for mini-dose (3-day) therapy but should not be overused to prevent resistance. As a result, they are no longer the preferred first-line treatment for uncomplicated UTIs.[25]

Fluoroquinolones: These antibiotics have high resistance rates but are preferred for pyelonephritis and prostatitis due to their excellent tissue penetration, especially in the prostate. While not the preferred choice for uncomplicated UTIs, fluoroquinolones may be used when other treatment options are unsuitable.[49][50][51] 

Fluoroquinolones and nitrofurantoin are mutually antagonistic and should not be used together. Recent FDA precautions regarding the adverse effects of fluoroquinolone should be considered carefully. For simple, uncomplicated cystitis, norfloxacin is suggested as it is specifically designed for lower UTIs. However, this drug should not be used for pyelonephritis due to poor renal tissue penetration.[52][53] Please see StatPearls' companion resource, "Quinolones," for more information.

Pivmecillinam: This unique β-lactam antimicrobial agent was approved by the FDA in April 2024 for the treatment of uncomplicated UTIs in women. Pivmecillinam (Pivya) is a prodrug of mecillinam, an extended-spectrum penicillin antibiotic, and is now available in the United States as a first-line treatment for uncomplicated female UTIs.

Key points about pivmecillinam include:

• The Infectious Diseases Society of America, the European Association of Urology, and the European Society for Microbiology and Infectious Diseases guidelines all recommend it as first-line therapy for uncomplicated UTIs.[39][54]
• Pivmecillinam has been used for 30 years in Europe and Canada for uncomplicated UTIs.
• This drug is particularly effective against E coli and other gram-negative Enterobacterales, including multiple drug-resistant and extended-spectrum β-lactamase (ESBL)-producing strains.[55][56][57] Susceptible organisms include E coli, Proteus mirabilis, and Staphylococcus saprophyticus. This drug is ineffective against Pseudomonas, Acinetobacter, Enterococcus, or other gram-positive urinary bacterial pathogens. 
• Pivmecillinam is recommended only when culture reports indicate sensitivity or when other first-line antibiotics have failed or cannot be used. Resistance among gram-negative Enterobacterales remains low, ranging from 1% to 6% in Europe, despite over 32 years of frequent usage.[56]
• A focused conceptual healthcare decision-analytic model has concluded that pivmecillinam is a cost-effective and recommended treatment for uncomplicated female UTIs caused by susceptible pathogens resistant to standard first-line antibiotics.[54] 
• Pivmecillinam is not recommended for pyelonephritis or suspected systemic infections due to its inadequate tissue penetration.[58] 
• The standard recommended dosage of pivmecillinam is 185 mg PO TID x 3 to 7 days, as clinically indicated. The typical retail cost of a treatment course in the United States is approximately $100.
• In Europe, the recommended dosage is 400 mg TID, based on evidence that this higher dosage is more effective.[59][60] 
• Prospective clinical trials found that a 5-day course was not more effective than 3 days of treatment, although a 7-day course appeared to be superior.[39][61]
• Pivmecillinam may be considered for use in the long-term prophylaxis of recurrent UTIs when other agents are ineffective or unsuitable, but it is not the preferred choice for empiric treatment in these infections.[62] This drug is generally considered safe for use during the first trimester of pregnancy.[63][64][65][66][67]
• Long-term therapy can lead to carnitine depletion. Patients should be monitored for common symptoms of carnitine deficiency, including muscle aches, fatigue, hyperammonemia, weakness, cardiomyopathy, and confusion. Please see StatPearls' companion resource, "Carnitine Deficiency," for more information.

Even without treatment, uncomplicated UTIs will spontaneously resolve in approximately 20% of women, particularly with increased hydration. The risk of a healthy, nonpregnant female developing acute pyelonephritis is minimal.

Failure of standard first-line therapy occurs in 10% to 18% of patients with uncomplicated UTIs, often due to factors such as bacterial resistance, patient non-compliance, renal failure, reduced drug absorption, use of sulfamethoxazole/trimethoprim, or undiagnosed urological issues (eg, incomplete bladder emptying, urolithiasis, prostatitis, pyelonephritis).[68][69] Risk factors for treatment failure include advanced age, chronic diarrhea, diabetes, foreign bodies in the urinary tract, male gender, and renal failure.[42]

Management of Recurrent Urinary Tract Infections

Managing recurrent UTIs generally involves optimizing personal hygiene, using vitamin C as a urinary acidifier, taking additional precautions after sexual contact, and considering prophylactic antibiotics or antiseptics such as nitrofurantoin.[38] Please see StatPearls' companion resource, "Recurrent Urinary Tract Infections," for more information.

Low-Dose Long-Term Antibiotic Prophylaxis for Recurrent Urinary Tract Infections 

Low-dose long-term antibiotic prophylaxis is the standard antimicrobial therapy for recurrent UTIs.[38]

• Nitrofurantoin is the most commonly used antibiotic for long-term, low-dose prophylactic therapy, typically administered at 50 mg QHS for at least 6 to 12 months. This drug is well tolerated and primarily affects the urinary tract, which minimizes adverse effects. Bacterial resistance is relatively low due to its multiple mechanisms of antibacterial activity, and allergies or intolerance are rare. Please see StatPearls' companion resource, "Recurrent Urinary Tract Infections," for more information.
• Sulfamethoxazole/trimethoprim or trimethoprim alone are alternative agents. 
• Norfloxacin and fosfomycin may also be used in selected cases.
• Pivmecilinam may be considered when other agents cannot be used due to resistance or other factors, although it is not typically preferred for long-term use.[62] Pivmecillinam is better tolerated than nitrofurantoin, and it effectively covers ESBL-producing and multiple drug-resistant strains of E coli, P mirabilis, and S saprophyticus. However, it is not recommended for Pseudomonas, Acinetobacter, Enterococcus, or other gram-positive urinary bacterial pathogens. 

Several adjunctive therapies, as mentioned below, have been suggested for the prevention of recurrent UTIs, although their efficacy varies.

• Cranberry (juice, pills, or extract) has been suggested as a preventive measure for UTIs, with some evidence supporting its efficacy, although the data remain contradictory.[70][71][72] Although some studies report a 30% to 40% reduction in UTIs, this effect is significantly less effective compared to low-dose antibiotic therapy.[71][73][74]
• D-mannose has been investigated as a prophylactic agent, with evidence indicating it may offer some benefit.[75][76][77][78][79] However, the available data are insufficient to formally recommend it.[70][73][80][81] Please see StatPearls' companion resource, "Recurrent Urinary Tract Infections," for more information.
• Estrogen vaginal cream, when applied twice weekly, can be beneficial for postmenopausal women with atrophic vaginitis.[73][82] 
• Increased fluid intake is helpful, especially in women with low urinary volumes.[82][83]

Methenamine is converted to formaldehyde in the bladder when the urinary pH is <5.5. Vitamin C is commonly used to help acidify the urine to achieve this pH level. While methenamine has shown some benefit in recurrent UTI prophylaxis, data are conflicting.[70][73] Methenamine may be a useful alternative to antibiotics in selected patients but should not be used in those with severe renal failure (GFR <10 mL/min).[25][84][85][86][87][88][89] Failure of methenamine, D-mannose, and cranberry prophylaxis typically indicates the need for low-dose, long-term antibiotic therapy.

Prophylactic treatment typically lasts 6 to 12 months. While it can be extended, limited data exist on its long-term effectiveness, and many patients may require ongoing prophylactic treatment due to recurrent UTIs.[38][90][91] Extending the prophylactic treatment period to 2 years has been suggested.[92][93] 

The diagnosis and management of recurrent UTIs are outlined in the American Urological Association Guidelines on Recurrent Urinary Tract Infections and StatPearls' companion resource, "Recurrent Urinary Tract Infections."[38][73] For relapsing infections (where the infecting organism is identical on all cultures), a careful examination should be done to look for a source, such as a poorly emptying bladder, a bladder diverticulum, or an infected stone. Please see StatPearls' companion resource, "Complicated Urinary Tract Infections," for more information.

Differential Diagnosis

The differential diagnoses of an uncomplicated UTI include:

• Bladder stones
• Complicated UTI
• Food or dietary issues
• Herpes simplex infection
• Medication adverse effects
• Overactive bladder
• Pelvic inflammatory disease
• Prostatitis
• Pyelonephritis
• Recurrent UTI
• Relapsing UTI
• Renal infarction
• Renal stones
• Sexually transmitted infections
• Urethritis
• Vaginitis

Prognosis

Most women with a UTI experience an excellent outcome, with symptoms typically resolving within 2 to 4 days of antibiotic treatment. However, nearly 30% of women will experience a recurrence within 6 months. Morbidity is more common in older, debilitated patients, individuals with significant comorbidities, or those with renal calculi. Other factors associated with recurrence include diabetes, underlying malignancy, chemotherapy, and chronic Foley catheterization. Mortality following an uncomplicated UTI is close to zero.[83][94] 

Factors predictive of a poor long-term outcome include:

• Advanced age
• Bladder stones
• Chemotherapy
• Chronic diarrhea
• Diabetes (particularly if poorly controlled)
• Incontinence
• Immobility
• Morbid obesity
• Nephrolithiasis
• Neuropathy or spinal cord injury
• Pelvic organ prolapse
• Poor overall health
• History of overactive bladder
• Malignancy
• Prior radiation therapy
• Renal failure
• Sickle cell anemia
• Urethral catheterization

Although mortality rates are low, the morbidity of UTIs is significant. Besides the distressing symptoms, the total cost of management can be prohibitive. Missed work and school are common, and in some cases, hospital admission may be required due to the severity of the symptoms.

Complications

Complications of uncomplicated UTIs may include:

• Chronic prostatitis
• Emphysematous pyelonephritis and cystitis
• Focal renal nephronia
• Hypertension
• Incontinence
• Persistent lower urinary tract symptoms
• Progression to complicated UTIs
• Prostatic abscess
• Pyelonephritis
• Renal abscess
• Renal failure
• Staghorn urinary calculi

Deterrence and Patient Education

Once a UTI is diagnosed, patients should be encouraged to increase their fluid intake. Patients should be advised to take their medication exactly as prescribed and to complete the full course of antibiotics, even if symptoms improve before their treatment is finished. In addition, patients should also be cautioned against taking prophylactic antibiotics unless specifically prescribed, as misuse can lead to increased bacterial resistance, making future UTIs more difficult to treat.

Preventative strategies are crucial in reducing the incidence and recurrence of UTIs, particularly in women. Those at higher risk should be educated on the following hygiene practices:

• Urinating after sexual intercourse can help reduce bacterial presence in the bladder, which can increase 10-fold following sexual activity.
• Wiping from front to back, not from the anal area forward, after urination is essential to prevent contamination of the introitus and periurethral areas with pathogenic enteric organisms from the rectum.
• Maintaining a high-volume, vigorous urine flow helps flush out bacteria and may aid prevention.
• Opting for showers instead of baths to minimize bacterial exposure.
• Using a gentle, fragrance-free liquid soap, baby soap, or baby shampoo for bathing is recommended, as liquid soaps are less likely to harbor bacteria than bar soap.
• Applying soap with a freshly cleaned, soft cotton or microfiber washcloth while bathing.
• Cleaning the vaginal area first to prevent the washcloth from transferring bacteria to the periurethral area if used on other parts of the body.

Some women with recurrent UTIs may benefit from prophylactic antibiotic use. Additionally, several nonmedical remedies may help manage UTIs. Anecdotal reports and some studies suggest that cranberry juice, D-mannose, methenamine, and probiotics may reduce the severity and frequency of UTIs in certain women.

Pearls and Other Issues

Key facts to keep in mind regarding "uncomplicated UTIs" include:

• A urine culture from a patient who has completed treatment is more informative than one obtained from a symptomatic patient after empiric therapy, especially if no culture was done to guide treatment.
• Asymptomatic bacteriuria generally should not be treated except in pregnant women or those undergoing an upcoming or recent invasive urologic procedure.
• Extensive evaluations should be avoided in healthy women with an uncomplicated UTI, other than urinalysis and culture.
• Bacteriuria and pyuria without symptoms are not diagnostic of a UTI.
• Fosfomycin and pivmecillinam should be considered in cases of initial treatment failure or when antibiotic resistance is present.
• Intravesical gentamicin and other antimicrobials can be valuable treatments of last resort when other therapies have failed or are not feasible.[95]

Enhancing Healthcare Team Outcomes

UTIs are best managed through an interprofessional approach. Understanding the barriers to better management of uncomplicated UTIs among primary care clinicians includes:

• Disagreement with guideline recommendations.
• Drug-related issues, such as medications being unavailable in pharmacies, insurance coverage problems, or high out-of-pocket costs for patients.
• Increased utilization of mid-level practitioners who may not be as familiar with treatment guidelines as physicians.
• Lack of applicability of guidelines to specific patient situations.
• Limited knowledge about new first-line agents, such as pivmecillinam.
• Organizational issues, such as emergency facilities and urgent care centers being less likely to order urine cultures compared to primary care offices.
• Patient allergies to first-line agents, which may lead to the use of fluoroquinolones instead of evidence-based alternatives recommended in guidelines.
• Patient compliance issues.
• Perception by some clinicians of a general lack of applicability of guidelines.
• The incorrect assumption is that urine cultures are never needed for uncomplicated UTIs.
• Unavailability of testing materials, such as microscopes, dipsticks, or culture supplies.[96][97][98]

These barriers can be addressed by raising awareness of the obstacles to optimal UTI management and through continuing medical education (CME) opportunities, such as online review sessions and peer-reviewed resources.[96][97][98]

Patient education is the key to preventing recurrences, and nurses play a critical role in this process. Primary care clinicians should refer patients with relapsing or recurrent UTIs who do not respond to prophylactic measures to urology.

Clinicians should collaborate closely with a pharmacist and/or infectious disease specialist to determine the most appropriate antibiotic treatment. Physicians should be aware of local bacterial resistance patterns. Pharmacists can confirm proper coverage, dosing, and treatment duration. Ensuring optimal antibiotic selection, correct duration, and medication adherence benefits both patient and community safety. Nurses are crucial in tracking patient progress, counseling on compliance, addressing patient questions, and reporting concerns or results to the clinical team.

All healthcare team members should monitor the patient's progress. If any issues arise, such as therapeutic failure or medication-related adverse events, they should promptly communicate their findings and involve the appropriate team members for corrective action. Early management of a UTI improves prognosis. Effective interprofessional collaboration and adherence to evidence-based guidelines are crucial in enhancing patient outcomes.[99][100]