Objective: To review treatment recommendations for empiric therapy of uncomplicated urinary tract infection (uUTI) in light of evolving antibiotic resistance and to consider use of guidelines to promote optimal practice.
Quality of evidence: PubMed was searched and additional relevant references were identified by reviewing articles found in the search. Guidelines were identified through discussion with family practitioners. Level of evidence was assessed for recommendations.
Main message: Many women have uUTIs. The treatment approach is usually empiric antimicrobial therapy without obtaining pretherapy cultures. Trimethoprim-sulfamethoxazole is standard first-line empiric treatment. While resistance to this drug is increasing, it remains only about 10% in community-acquired Escherichia coli in Canada. Concerns about increased resistance have contributed to greater use of fluoroquinolones, but widespread empiric use of this class of medications might promote resistance to fluoroquinolones. Hence, fluoroquinolones should not be considered first-line therapy. While guidelines for treatment of uUTIs have been developed, their usefulness is compromised by their conflicting recommendations.
Conclusion: Trimethoprim-sulfamethoxazole and nitrofurantoin remain first-choice empiric therapy for uUTIs. Development of guidelines relevant to family physicians and community education programs that incorporate local susceptibility patterns are important strategies for promoting optimal practice.