Urinary Tract Infection (UTI) Treatment

Classification First

1. Uncomplicated Lower UTI (Acute Cystitis) in Women

• Cefpodoxime, cefdinir, cefaclor (3-7 day courses)
• Amoxicillin-clavulanate (3-7 days) - less effective against Enterobacteriaceae

Symptom relief: Phenazopyridine 100-200 mg up to three times daily after meals for up to 2 days (urinary analgesic) - use alongside antibiotics only; can mask fever and stains contact lenses.

2. Pyelonephritis (Upper UTI)

Outpatient (mild-moderate, no vomiting):

• Ciprofloxacin 500 mg twice daily x 7 days (or 1000 mg XR once daily x 7 days)
• Levofloxacin 750 mg once daily x 5 days
• TMP-SMX DS x 14 days (if susceptibility confirmed)

Inpatient (severe, vomiting, sepsis):

• Ceftriaxone 1-2 g IV every 24 hours
• Gentamicin/aminoglycoside IV (associated with better outcomes in high-resistance areas)
• Ciprofloxacin IV 400 mg every 12 hours
• Total course: 7-14 days (5-7 days adequate for fluoroquinolones)

3. Complicated UTI (including catheter-associated, men, structural abnormalities)

• Individualize based on culture & sensitivity
• Treat underlying anatomic/functional abnormality when possible
• Empiric options for severe/hospitalized:
  • Piperacillin-tazobactam 4.5 g IV every 8 hours x 7 days
  • Meropenem 1 g IV every 8 hours x 4-5 days, then oral step-down
  • Plazomicin 15 mg/kg IV once daily (for ESBL/resistant organisms)
  • Meropenem-vaboractam for carbapenem-resistant organisms
• Total course: typically 10-14 days

4. Special Populations

Pregnancy

• Nitrofurantoin or oral cephalosporins are preferred (safe for fetus)
• TMP-SMX: avoid in first trimester and near term
• Fluoroquinolones: contraindicated
• Asymptomatic bacteriuria in pregnancy MUST be treated (risk of pyelonephritis/preterm birth)
• Treat cystitis for 7 days

Men

• UTI in men is considered complicated - evaluate for prostatitis/structural cause
• Fluoroquinolones preferred (good prostate penetration)
• Duration: 7-14 days (longer if prostatitis suspected)

Recurrent UTI in Women

• Long-term prophylaxis (if >2 infections/6 months):

• Postcoital prophylaxis (if UTI is coitus-related): single-dose nitrofurantoin 50-100 mg, TMP-SMX 40/200 mg, or TMP 100 mg after intercourse
• Non-antibiotic prevention: increase fluid intake >1.5 L/day, avoid spermicides, D-mannose (420 mg to 2 g daily) especially for recurrent E. coli infections
• Cranberry products (juice/tablets) may have modest benefit for prevention per recent network meta-analysis (PMID 39030132)

Funguria (Candida UTI)

• Treat only if symptomatic
• Fluconazole 400 mg x 1 day, then 200 mg daily x 7-14 days
• Fluconazole-resistant Candida: liposomal amphotericin B (7-10 days)

5. Key Resistance/Stewardship Points

• Check local antibiogram - TMP-SMX resistance exceeds 20% in parts of western/southern USA
• ESBL-producing E. coli: use nitrofurantoin (6% resistance) or fosfomycin (3% resistance)
• Avoid fluoroquinolones for uncomplicated cystitis - preserve for complicated/upper tract infections
• Amoxicillin alone is not recommended due to high resistance; also selects for Klebsiella
• Overtreatment of asymptomatic bacteriuria promotes resistance - only treat in pregnancy and pre-urologic procedures

Recent Evidence Update

TSH = 12 mIU/L: What It Means and What to Do

Step 1 - Interpret the Value

Step 2 - Classify Based on Free T4 Result

Scenario A: TSH 12 + Normal fT4 = Subclinical Hypothyroidism

Who to treat:

• TSH ≥10 mIU/L - treat (this patient qualifies)
• TSH 5-10 + symptoms, elevated LDL, or positive thyroid antibodies (TPO-Ab) - also treat

Additional workup before starting treatment:

• TPO antibodies (anti-thyroid peroxidase) - if positive, higher risk of progression to overt hypothyroidism; also confirms Hashimoto's thyroiditis
• Lipid panel - hypothyroidism raises LDL
• Repeat TSH in 2-3 months to confirm persistence (rule out transient causes)

Scenario B: TSH 12 + Low fT4 = Overt Hypothyroidism

Symptoms to expect:

Associated lab abnormalities:

• Elevated LDL cholesterol
• Macrocytic anemia (elevated MCV)
• Hyponatremia
• Elevated CK and AST (muscle dysfunction)

Treatment: Levothyroxine (L-T4)

Dosing

How to Take It (critical for absorption)

• Empty stomach - 30-60 minutes before breakfast, OR at bedtime (2-3 hours after last meal)
• Food reduces absorption by ~40%
• Space 4 hours away from: calcium, iron supplements, antacids, proton pump inhibitors, cholestyramine, sucralfate, soy protein

Drugs that increase levothyroxine metabolism (may need higher doses):

Monitoring

Special Situations

Most Common Cause to Consider

A 2025 ETA guideline on levothyroxine optimization (PMID 40622204) reinforces monotherapy with L-T4 as the standard of care, with careful attention to formulation consistency and absorption factors.

Osteoarthritis (OA) Treatment

Step 1 - Non-Pharmacological (Core Treatment - ALL Patients)

Exercise (Strongest Evidence)

• Aerobic, strengthening, aquatic - all are effective; a 2025 BMJ network meta-analysis (PMID 41093618) confirms exercise as the most effective non-pharmacological intervention for knee OA
• Quadriceps strengthening is especially important for knee OA (weakness may precede disease onset)
• Low-impact activity (walking, swimming, cycling) - does NOT worsen OA in normal joints
• Supervised, unsupervised, and aquatic exercise are all recommended

Weight Loss

• Sustained weight loss in overweight/obese patients is moderately recommended (AAOS)
• Reduces mechanical load on weight-bearing joints (knees, hips)

Patient Education & Self-Management

• Self-management programs strongly recommended
• Activity modification - avoid high-impact, joint-injuring activities

Assistive Devices

• Canes (contralateral hand) - reduce joint loading
• Braces/splints - unloader braces for unicompartmental knee OA
• Walking shoes with good cushioning; foot orthoses for malalignment

Physical & Occupational Therapy

• Neuromuscular training in combination with traditional exercise (moderately recommended)
• Joint protection techniques, adaptive equipment

Step 2 - Pharmacological Treatment

Topical Agents (First Preference - Fewer Systemic Effects)

Oral Analgesics

Acetaminophen (Paracetamol)

• Up to 2 g/day (some guidelines allow up to 3 g/day, but higher doses increase renal/hepatic risk)
• Limited efficacy - treatment effect is small and often not clinically meaningful
• Conditionally recommended - useful in patients who cannot tolerate NSAIDs
• Safe in elderly, renal impairment, GI risk patients

Oral NSAIDs (Most Effective Oral Option)

• Take with food; add PPI (or misoprostol) if high GI risk (age ≥60, prior GI bleed, concurrent steroids)
• Celecoxib is safer for the GI tract but carries cardiovascular risk
• Use lowest effective dose; start on "as-needed" basis before committing to daily dosing
• Avoid in CKD, heart failure, decompensated liver disease

Duloxetine (SNRI)

• Recommended for patients who cannot tolerate NSAIDs or have central sensitization component to pain
• 60 mg once daily; useful when depression or widespread pain co-exists with OA
• Inhibits pain processing centrally

Opioids / Tramadol

• Not recommended by AAOS for knee OA
• Harrison's: "less efficacious than oral NSAIDs" with significant addiction risk and side effects (dizziness, sedation, constipation, urinary retention)
• Reserve only for patients not candidates for surgery who have failed all other therapies

Step 3 - Intra-Articular Injections

Corticosteroids

• Moderately recommended by AAOS for short-term relief
• Methylprednisolone, triamcinolone acetonide
• Effect lasts 4-8 weeks; suitable for acute flares
• Do not repeat more than 3-4 times per year in the same joint (risk of cartilage damage with repeated use)

Hyaluronic Acid (Viscosupplementation)

• Not recommended by AAOS
• Harrison's: "most evidence suggests little efficacy versus placebo"
• Still used clinically; 3-5 weekly injections; mild-to-moderate injection site pain

Platelet-Rich Plasma (PRP)

• Insufficient rigorous evidence; not yet standard of care
• May be considered in selected cases at specialized centers

AAOS Evidence-Based Guideline Summary (Knee OA)

Step 4 - Surgical Treatment

High Tibial Osteotomy (HTO)

• For younger patients (<60) with unicompartmental (medial) knee OA and varus deformity
• Realigns mechanical axis to offload the diseased compartment
• Delays need for total knee replacement

Unicompartmental Knee Arthroplasty (UKA)

• For isolated single-compartment OA
• Faster recovery, better preserved proprioception vs. TKA
• Suitable for older, lower-demand patients with unicompartmental disease

Total Knee Arthroplasty (TKA)

• For severe, end-stage tricompartmental knee OA
• Most effective procedure for severe OA; high success rate
• Indications: failed conservative therapy, severe pain limiting daily function, radiographic evidence of advanced joint destruction

Total Hip Arthroplasty (THA)

• Gold standard for severe hip OA

Special Notes

• Asymptomatic OA (incidental radiographic finding): no treatment required
• Erosive OA of the hands: inflammatory variant; hydroxychloroquine may be tried
• Repeat TSH annually if patient is on levothyroxine - hypothyroidism exacerbates OA symptoms
• OA of the spine: NSAIDs provide limited benefit; physical therapy and core strengthening are primary

Recent evidence update: 2024 EULAR guidelines (PMID 38212040) for non-pharmacological management of hip and knee OA emphasize exercise, weight management, and education as the non-negotiable core of all OA care.