Increasing antimicrobial resistance and the management of uncomplicated community-acquired urinary tract infections

Ann Intern Med. 2001 Jul 3;135(1):41-50. doi: 10.7326/0003-4819-135-1-200107030-00012.


Community-acquired urinary tract infections (UTIs) are among the most common bacterial infections in women. Therapy for these infections is usually begun before results of microbiological tests are known. Furthermore, in women with acute uncomplicated cystitis, empirical therapy without a pretherapy urine culture is often used. The rationale for this approach is based on the highly predictable spectrum of etiologic agents causing UTI and their antimicrobial resistance patterns. However, antimicrobial resistance among uropathogens causing community-acquired UTIs, both cystitis and pyelonephritis, is increasing. Most important has been the increasing resistance to trimethoprim-sulfamethoxazole (TMP-SMX), the current drug of choice for treatment of acute uncomplicated cystitis in women. What implications do these trends have for treatment of community-acquired UTIs? Preliminary data suggest that clinical cure rates may be lower among women with uncomplicated cystitis treated with TMP-SMX when the infecting pathogen is resistant to TMP-SMX. Women with pyelonephritis also have less bacterial eradication and lower clinical cure rates when treated with TMP-SMX for an infection that is resistant to the drug. Therefore, in the outpatient setting, identifying risk factors for TMP-SMX resistance and knowing the prevalence of TMP-SMX resistance in the local community are important steps in choosing an appropriate therapeutic agent. When choosing a treatment regimen, physicians should consider such factors as in vitro susceptibility, adverse effects, cost-effectiveness, and selection of resistant strains. Using a management strategy that takes these variables into account is essential for maintaining the safety and efficacy of treatment for acute UTI.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.
  • Review

MeSH terms

  • Anti-Infective Agents, Urinary / pharmacokinetics
  • Anti-Infective Agents, Urinary / therapeutic use*
  • Bacterial Infections / drug therapy
  • Bacterial Infections / microbiology
  • Community-Acquired Infections / drug therapy*
  • Community-Acquired Infections / microbiology*
  • Drug Resistance, Microbial*
  • Female
  • Humans
  • Microbial Sensitivity Tests
  • Risk Factors
  • Treatment Outcome
  • Trimethoprim, Sulfamethoxazole Drug Combination / therapeutic use*
  • Urinary Tract Infections / drug therapy*
  • Urinary Tract Infections / microbiology*


  • Anti-Infective Agents, Urinary
  • Trimethoprim, Sulfamethoxazole Drug Combination