Treating urinary tract infections in the era of antibiotic resistance

ABSTRACT

Introduction

Urinary tract infections (UTIs) are associated with 25–40% of antibiotics consumed in primary care and are, therefore, driving antibiotic resistance. The worldwide increase in antibiotic resistance especially in Escherichia coli has complicated the treatment choices for UTIs and absence of effective oral antibiotics may lead to increasing need for more effective treatments.

Areas covered

In this review we focus on the importance of the correct diagnosis of UTI as based on proof of urinary pathogens in the urine and discuss diagnostic measures including microscopy, dipstick, and culture. Antibiotic treatment can often await diagnostic measures with pain relief such as ibuprofen. The risk of an uncomplicated UTI leading to pyelonephritis is low (1–2%) and presence of bacteria in the bladder leaves some time for the immune system to react. Three antibiotics are recommended as based on their activity, and low propensity to select for resistance, i.e. nitrofurantoin, fosfomycin, and pivmecillinam, and in general, 3–5 days of treatment will suffice.

Expert opinion

Understanding the usual benign course of uUTIs can help reduce antibiotic treatment in many cases, e.g. starting treatment by pain relief and awaiting the course of infection without antibiotics. Better rapid tests in primary care are urgently needed to enforce such policies.

KEYWORDS:

• Antibiotics
• diagnosis
• pyelonephritis
• uncomplicated urinary tract infection
• nitrofurantoin
• fosfomycin
• pivmecillinam

Article highlights

• Urinary tract infections (UTIs) are among the most common bacterial infections in primary care and in hospitals.

• The risk of uncomplicated UTI (uUTI) leading to pyelonephritis is 1-2%

• At least 30% of uUTIs will clear without antibiotic treatment, but can be relieved by pain killers such as ibuprofen

• Diagnostic measures are important to prove presence of urinary pathogens and albeit microscopy and dipstick are available and easily performed in primary care to support the diagnosis, we urgently need validated rapid tests with high sensitivity and specificity.

• Nitrofurantoin, fosfomycin or pivmecillinam are recommended for both empiric and directed treatment based on their activity and low propensity for development of resistance.

• Short duration, i.e. 3-5 days of treatment, will most often suffice

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.