The Untold Burden of Uncomplicated UTIs: Addressing Recurrence and Treatment Gaps

Uncomplicated urinary tract infections remain a common and costly condition in the United States, with effective treatment complicated by recurrence and antibiotic resistance. In a recent AJMC Peer Exchange moderated by Ryan Haumschild, PharmD, MS, MBA,vice president of ambulatory pharmacy at the Winship Cancer Institute of Emory University in Atlanta, Georgia, a panel of experts explored the clinical burden of these infections, addressing treatment response and resistance patterns in the context of both current and emerging therapies. The discussion also addressed how payers influence treatment access, effectiveness, and overall cost of care.

Uncomplicated UTI Disease Burden, Recurrence, and Resistance

Urinary tract infections (UTIs) are among the most common bacterial infections in the United States, affecting approximately half of women by age 35. The infections are associated with substantial health care costs and reduced quality of life.1,2 They are classified as uncomplicated or complicated, the latter involving anatomical abnormalities, resistant pathogens, or indwelling devices that increase biofilm risk and hinder treatment.3 Although uncomplicated UTIs are typically easier to treat, they may become recurrent, defined as 2 or more symptomatic infections within 6 months or 3 within 12 months, often caused by the same pathogen.4 Without appropriate management, both types can progress to kidney damage or sepsis.3

Uropathogenic Escherichia coli causes up to 80% of uncomplicated UTIs, though other gram-negative (eg, Klebsiella pneumoniae, Proteus mirabilis) and gram-positive (eg, Staphylococcus spp, Enterococcus faecalis) pathogens may be involved. Recurrence is common and may involve new or persistent pathogens.1 Empiric antibiotics are often prescribed without culture or susceptibility testing, relying on national guidelines and local resistance profiles.1,5 The Infectious Diseases Society of America (IDSA) recommends trimethoprim-sulfamethoxazole (trim-sulfa), nitrofurantoin, or fosfomycin as first-line therapy.5 However, recurrent infections increase antibiotic exposure and resistance, heightening risks for treatment failure, morbidity, health care costs, and broader resistance from broad-spectrum agents.1

In a retrospective study of nearly 149,000 US adults with uncomplicated UTIs, 19% experienced recurrence, and antibiotic nonsusceptibility increased with each episode.1 These trends underscore the need for ongoing surveillance of recurrence patterns and susceptibility trends to guide therapy, especially as E coli susceptibility has declined over the past 30 years.1,3 With data supporting this decline, study investigators have reported a 22-fold increase in extended-spectrum β-lactamase (ESBL)–positive E coli isolates from 2004 to 2014 and rising resistance from 2014 to 2019.6,7

Stakeholder Insights

Clinical Definitions, Risk Factors, and Evolving Resistance Patterns

Thomas M. Hooton, MD, a professor at the Miller School of Medicine at the University of Miami in Florida, noted that although uncomplicated UTIs may not be increasing, “what really is increasing [with] a strong trend is the incidence of antimicrobial resistance.” He explained that accurate data are limited because UTIs are “not a reportable disease,” and the term “means different things to different people.” He defined it as infections “mainly in women, but in men or women who have no obvious structural anatomic abnormality” and no systemic symptoms. “An uncomplicated UTI should manifest as just dysuria, frequency, urgency, burning…. [Anyone] sick enough to go into the hospital does not have an uncomplicated UTI,” he said. He also cited rising resistance in E coli and Klebsiella, mainly due to ESBLs. “Trim-sulfa...used to be the most common [antibiotic], and we’ve seen a huge increase in resistance,” he said, whereas “nitrofurantoin...has very low prevalence of resistance [that] doesn’t seem to be increasing that much.” Haumschild emphasized the importance of stewardship and selecting appropriate therapy as resistance trends evolve.

Wendy Cheng, PhD, MPH, managing director at Berkeley Research Group in Boston, Massachusetts, explained that social determinants of health—including socioeconomic status (SES), health care access, and geography—can influence UTI prevalence and outcomes, though “there’s not a lot of literature that offers direct evidence.” She stated that “lower individual-level SES and community-level SES [are] linked to higher rates of infections, especially antimicrobial-resistant ones, because often [there is] less than optimal health and health care access.” However, she cautioned, “individuals with low SES who don’t have any or good insurance may not seek care. If we don’t have visibility to those cases, we may artificially see that UTI is less prevalent, [which is] why we often see mixed results regarding the association between SES and prevalence.”

On outcomes, Cheng noted that failure and recurrence vary by region. “In the South, the risk of treatment failure is higher…and this is frequently linked to misuse and overuse of antibiotics because of the availability of over-the-counter options and pharmacies outside the US,” she said. This “drives up the resistance levels, which then is tied to a higher likelihood of treatment failure,” Cheng said, and reflects “the underlying issue of insufficient insurance coverage and health care access for people with low SES.” She added that in resource-limited communities, there may be “a higher reliance on empirical treatment rather than targeted treatment, [which] could then impact treatment outcomes.”

Debra Fromer, MD, chief of female pelvic medicine and reconstructive surgery at Hackensack University Medical Center in New Jersey, emphasized that recurrence of uncomplicated UTIs is a significant burden for patients and clinicians, especially in urology, obstetrics and gynecology (ob-gyn), and family medicine: “Recurrence is a problem and the rates of recurrence are higher than one would think—30% to 44% of patients in the literature develop recurrent UTIs, [often] within 3 months,” Fromer said. She defined recurrent UTIs as “2 symptomatic culture-proven UTIs within 6 months or 3 within a year,” stressing that “the culture-proven part is fairly important.” Without proper confirmation, she warned, “we can misdiagnose things like bladder cancer, especially in women who are often misdiagnosed as having recurrent UTI.”

Fromer noted that recurrence risk increases with age, prior UTIs, antibiotic use, and immunocompromised status, although “resistance is No. 1.” She cited that “resistance rates are very high for sulfur drugs, [ranging] from 17% to 29%...and fluoroquinolone resistance, between 10% and 23%.”

Haumschild added that tracking recurrence and resistance is difficult “without cultures, without appropriate documentation…especially if patients are presenting at a community hospital that doesn’t [have] the same EMR [electronic medical record] as their ongoing PCP [primary care physician].”

Patient Education and Disease Burden

Patient education is vital in reducing recurrence and improving outcomes for patients with uncomplicated UTIs. Haumschild emphasized that providers must help patients “connect with the adherence piece and explain why that is so important to finishing their treatment regimen.” He invited panelists to share strategies for fostering better understanding and engagement.

Katie S. Murray, DO, a professor in the Department of Urology at NYU Grossman School of Medicine and chief of the urology service at Bellevue Hospital Center in New York, New York, agreed, explaining that “education is really the mainstay…making sure patients try to understand what causes antibiotic resistance. The onus is on us to break that down for patients.” She added, “Patients often have symptoms that may not be a culture-proven urinary tract infection, [making it essential to emphasize] the importance of having urinalyses followed up with urine cultures.”

She also described real-world challenges such as “transportation, insurance, [and] language,” and the need to support patients in “completing their antibiotics and de-escalating those antibiotics when necessary.” To support adherence, Murray suggested expanding communication via “automated messages from our EMRs [so] it doesn’t have to always be a physical person doing those touchpoints.” Haumschild added that financial barriers also play a role, warning, “We know that prior authorizations can be a barrier. My biggest concern is choosing a therapy, not knowing that the patient might have some financial toxicity. [Then] they end up not taking it, and there’s a readmission or progression of their UTI.”

Hooton noted that “[recurrent UTIs] present the same way [as initial episodes]: dysuria, frequency, urgency, but resistance leads to more visits, more cost.” He emphasized, “In terms of the actual patient being able to tell us, ‘I have a resistant bug,’ that’s just not possible without getting a culture.” Describing the broader burden, he cited “days of symptoms, days lost from work, days sick enough to be in bed…sexual activity is affected, household chores—everything.”He concluded, “It’s just an awful disease, a nasty disease that causes a lot of morbidity.”

Minimizing Antibiotic Resistance

Balancing effectiveness with stewardship is key to minimizing resistance. Haumschild noted, “We always have to balance that with the stewardship factor [and ensure we’re] not creating too much exposure in the community.”

Fromer contrasted her approach with what she sees in community practice. “If a patient is minimally [symptomatic] or even asymptomatic, we may not treat that as long as there are no risks of progression, [and symptoms may resolve] with hydration alone.” She emphasized obtaining cultures before initiating antibiotics: “Once you take that first antibiotic pill, we may not be able to culture an organism, then we wind up chasing our tail.” For complex cases, she offers workarounds: “I send patients out with a sterile cup: [I tell them,] just urinate in the cup and have your granddaughter bring it in, keep it in the refrigerator.”

Fromer also is concerned about community providers bypassing cultures and documentation. “They’re often giving people just an empiric fluoroquinolone or cephalosporin, not documenting that this was a UTI, and that is the biggest nightmare for antibiotic stewardship,” she said. In regions with high ciprofloxacin resistance, “patients are going to have treatment failure, and it can go on like that for months,” she said. To address this, she tries to delay antibiotics for at least 7 days for some patients “to stop that pattern of overtreatment.” Murray agreed but acknowledged that “patients end up going to the urgent care because their symptoms aren’t well controlled. It really goes back to that patient education piece.”

Current Standard of Care Treatments for Uncomplicated UTIs

The 2010 IDSA guidelines recommend nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin as preferred first-line treatments for uncomplicated UTIs based on efficacy and safety.5 Fluoroquinolones should be reserved for when other options are unsuitable because of their association with resistance and serious adverse events, whereas β-lactams are considered less effective.5

Although the guidelines are nearly 15 years old, a recent cohort study of more than 57,000 UTI episodes in women in the US (2012-2021) found that guideline-concordant therapies remain effective compared with fluoroquinolones and are superior to β-lactams in efficacy and adverse events, supporting their continued use in outpatient stewardship programs.8 First-line therapies were linked to lower 30-day revisit rates for UTIs than fluoroquinolones (−1.78%) and β-lactams (−6.40%).8

Survey data indicate that approximately 80% of patients responded to empiric therapy, whereas 20% required a treatment change.9 Trimethoprim-sulfamethoxazole was the most commonly preferred empiric therapy (76%), followed by nitrofurantoin (57%).9

In a large US cohort of female outpatients with uncomplicated UTIs, treatment failure occurred in 16.7% of cases, with rates varying by empiric antibiotic choice.10 Failure was most common with fosfomycin (30.1%), followed by β-lactams (19.2%), trimethoprim-sulfamethoxazole (17.1%), fluoroquinolones (15.8%), and nitrofurantoin (15.3%).10 Patients with a history of prior antibiotic failure had the highest risk (33.9%), highlighting the need to consider treatment history and local resistance patterns when selecting empiric therapy.10

Stakeholder Insights

Clinical Guidelines and Standard Antibiotics

Although clinical guidelines support uncomplicated UTI management, their utility may be limited. Murray explained that “guidelines are often to just give somebody that quick reference of what we should be doing,” but real-world factors such as resistance and local antibiograms “make the recommendation of ‘This is the antibiotic to use across the board’ nearly impossible.”

She added that IDSA guidelines are outdated. “The guidelines [are] from 2010 and are now 15 years old. [However, they recommend] not using a fluoroquinolone, but looking at a sulfa-, nitrofurantoin-, [or] fosfomycin-type of medication in an acute short-term period.”

Haumschild agreed. “There’s so much changing in the space that updated guidelines are going to be extremely helpful, not only [for] subspecialists, but even those general practitioners in more rural environments,” he said. He stressed the need for “something [general practitioners] can look to [to] drive appropriate stewardship of therapy and appropriate selection.”

Hooton confirmed that updated IDSA guidelines are expected soon: “They should have been out 2 or 3 years ago…. I suspect [in] the next year or 2, they’ll be out. My guess is they’ll position β-lactams way ahead of fluoroquinolones…. Fluoroquinolones really should not be used in this condition.”

When asked about patient response rates to standard antibiotics for uncomplicated UTIs, Cheng said that outcomes “depend on the microorganism [and] local antimicrobial resistance levels, whether the antibiotic is given empirically or targeted, and patient factors.” She noted, “If we look at treatment failure as a metric for effectiveness, nitrofurantoin is about 15%, which is below the national average of 17%,” whereas trimethoprim and β-lactams are “higher, around 17% to 19%,” partly due to “the average resistance rate of these antibiotics in the country.” Cheng added that “fosfomycin is not commonly prescribed in the US; [it is] used less than about 5% of the time, largely because it has been pretty costly, and its average treatment failure rate tends to be higher, about 30%.” However, she emphasized that “treatment failure varies greatly by region.” For example, in New Hampshire, she said, “E coli tends to be quite susceptible to fosfomycin, more so than nitrofurantoin and trimethoprim.”

Cost-Effectiveness

Addressing cost-effectiveness, Cheng emphasized that “effectiveness is tied to the resistance levels. So to the extent that two antibiotics are comparable in cost, understanding the local resistant levels of the microorganisms, which impacts the likelihood of the infection resolution, could really help identify the more cost-effective treatment choice.”

Haumschild agreed, adding, “There’s a trade-off of total cost of care. A therapy might be expensive, but if it reduces failures, reduces those readmissions, [offers] shorter duration of therapy…[and leads to] clearance of that uncomplicated UTI, [then] there’s a lot of value in that.” He stressed that “with multiple therapies, it’s always important for payers not just to think about product cost alone, but [also] downstream variables that could impact that health plan’s covered lives.”

Hooton emphasized that although “trim sulfa and fluoroquinolones are dirt cheap, they shouldn’t be used. Unless you know the bug is susceptible, those drugs shouldn’t be used. Nitrofurantoin is not necessarily dirt cheap, but it’s effective.”

Although there are limited scenarios where fluoroquinolone might be considered, Hooton emphasized, “fluoroquinolone is really at the end of the food chain for an uncomplicated UTI.” He also noted, “The FDA [has] a warning with fluoroquinolones. They should not be used for simple infections like this, and I think it’s a liability for physicians to do it,” concluding, “I’m disheartened by how frequently fluoroquinolones are used…. It’s just unbelievable and unacceptable.”

Duration of Therapy

Fromer addressed the importance of treatment duration, noting that adherence tends to vary in 2 ways. “I will see patients who say 3 days isn’t enough. I need at least 7 days or 10 days…and they’re still symptomatic after 3 days of treatment,” she said. Lingering symptoms, she emphasized, don’t always mean ongoing infection. “It only takes 3 days with a sulfa drug, or 5 days with nitrofurantoin… to clear an organism, but they still may have those symptoms lingering on for a week or two,” Fromer said. In such cases, she recommended education and symptomatic relief, not prolonged antibiotics.

Conversely, Fromer described patients who stop treatment too early. “They take 2 days’ worth, and they’re like, I’m better, and I’m going to stop.” She warned: “This is your nightmare…. [They’re] at risk for resistance. They may have cleared 99% of the drug in those first 2 days, but that 1%…is likely to replicate and then need another course of antibiotics. But this time, it’s going to be resistant to nitrofurantoin.”

Unmet Needs and Emerging Therapies for Uncomplicated UTIs

​Recurrent UTIs are a widespread clinical and economic burden, affecting women across all demographics and contributing an estimated $2 billion annually in US health care costs.11 The American Urological Association (AUA) recommends thorough evaluation, including history, pelvic examination, and confirmation of prior culture-proven episodes, with urinalysis and culture obtained before treatment. First-line treatments involve short courses of nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin, guided by local resistance patterns. Preventive measures may include prophylactic antibiotics and cranberry supplements.

In 2019, the FDA updated its guidance for uncomplicated UTI trials, implementing stricter inclusion criteria and efficacy end points, influencing the evaluation of new therapies.12 Recently, the FDA approved 3 new agents for uncomplicated UTIs, including gepotidacin (Blujepa), sulopenem etzadroxil with probenecid (Orlynvah), and pivmecillinam (Pivya).13-15

Gepotidacin, the first-in-class new oral antibiotic for UTIs in nearly 30 years, was evaluated in the phase 3 EAGLE-2 (NCT04020341) and EAGLE-3 (NCT04187144) trials.13,16 It demonstrated noninferiority to nitrofurantoin in EAGLE-2 (50.6% vs 47.0%; adjusted difference, 4.3%; 95% CI, –3.6% to 12.1%) and superiority in EAGLE-3 (58.5% vs 43.6%; adjusted difference, 14.6%; 95% CI, 6.4%-22.8%).16

Sulopenem etzadroxil with probenecid was studied in the phase 3 SURE 1 (NCT03354598) and REASSURE (NCT05584657) trials. In patients with ciprofloxacin-resistant uncomplicated UTIs, sulopenem demonstrated a higher composite response rate than ciprofloxacin (48.1% vs 32.9%; difference, 15.3%; 95% CI, 4.3-25.8; P = .006), although it did not meet noninferiority criteria in ciprofloxacin-susceptible populations.15,17 In REASSURE, sulopenem outperformed amoxicillin/clavulanate in patients with susceptible pathogens (61.7% vs 55.0%; difference, 6.7%; 95% CI, 0.3%-13.0%).15,17

Pivmecillinam was assessed in 3 pivotal phase 3 trials. It showed higher response rates than placebo (62% vs 10%; difference, 52%; 95% CI, 41%-62%) and ibuprofen (66% vs 22%; difference, 44%; 95% CI, 31%-57%) (NCT01849926), and was comparable to cephalexin (72% vs 76%; difference, –4%; 95% CI, –16% to 7%).14,18

Stakeholder Insights

Unmet Needs and Economic Burden

Therapeutic gaps in uncomplicated UTI care persist amid rising recurrence and resistance. “Despite using our guidelines and antibiotics, we heard some resistance rates in communities of 10% to 25% [for] some of these drugs,” Murray said. “[Lack of adherence] is contributing to antibiotic resistance,” which is “forcing us into this rabbit hole of having less and less options… to treat these patients,” she noted.

Murray added that “the majority of these patients don’t ever get to a urologist,” instead receiving care in primary or urgent care. “It’s so important [that] we’re all on the same page [and] not contributing to resistance patterns,” she said.

Treatment failure in uncomplicated UTIs carries clinical and economic burdens. Cheng explained that it typically means needing another oral or intravenous antibiotic, or an emergency department or inpatient visit. “There’s obvious clinical burden… but additional health resources translate to considerable economic cost…. [Patients with treatment failure] cost about $850 more per UTI episode compared with those [whose treatments] don’t fail.”

She added that failure “leads to reduced quality of life and productivity. [Patients are] in pain, can’t go to work, or take care of somebody…. All of that adds to the indirect cost.” If failure is due to resistance, it “serves as a risk factor for recurrence, fosters the growth of that bacteria strain, [and] exerts selection pressure, exacerbating this whole issue of resistance.”

Haumschild agreed: “There’s direct cost to the patient [for] readmissions, but also [there is] productivity loss.” He emphasized that stewardship is “not just for the patient, but for our greater community.”

AUA Guideline Recommendations

As a urologist, Murray noted, “We look at our [AUA] guidelines—they’ve become very popular,” explaining that recurrent UTI recommendations outline “how do we evaluate, diagnose…[what] further workup may be necessary, antibiotic treatments…[and] is there an option for a prophylaxis [for this] very specific patient population.” She emphasized the need to first rule out other causes, such as cancer.

For evaluation, Murray said, “The American Urologic Association says we need to be doing a history and physical, including a pelvic exam [to ensure] they meet the criteria of uncomplicated urinary tract infection” with “normal anatomy [and] normal functional anatomy.” She added, “Obviously, they recommend a culture [but] don’t recommend upfront cystoscopy or other imaging.”

Murray summarized treatment guidance, noting that clinicians may “start patients on something while you’re pending that culture…but ensure that you escalate or de-escalate based upon the culture.” First-line options include “nitrofurantoin, trimethoprim-sulfa, and fosfomycin,” she said, adding, “In an asymptomatic patient, we should not or do not have to do any follow-up urinalysis or urine culture to confirm clearance.”

Emerging Therapies

Newly approved therapies are expanding treatment options for uncomplicated UTIs. Pivmecillinam, which the FDA approved in April 2024, “acts against gram-negative organisms—it interferes with the biosynthesis of the bacterial cell wall in a slightly different way than penicillins and cephalosporins,” Fromer said. She added, “Clinical efficacy is reported between 82% and 95%, and adverse events are similar to other penicillins—nausea, rash, vulvovaginitis—[and are] generally very well tolerated.” Though not widely used, Fromer said, “it’s hard to get approval, [and] it has not been added to susceptibility panels…. But it’s great to see novel agents. The more drugs that are there for us to use, the greater we can dilute the resistance patterns.”

Sulopenem etzadroxil/probenecid, approved by the FDA in October 2024, was described by Murray as a penem-class β-lactam that “inhibits bacterial cell wall synthesis [and was] superior to ciprofloxacin, about 62% vs about 35%,” with adverse effects such as “diarrhea, nausea, headache, vaginal yeast infection, [and] vaginitis.” Haumschild stressed, “It’s great to create awareness around these new therapies, especially as payers are developing authorization criteria and many providers might have patients [who] potentially could be eligible.”

Another promising candidate is gepotidacin, which Hooton described as “a fluoroquinolone-sparing agent to add to our armamentarium.” It “acts on DNA gyrase and topoisomerase…[with] very balanced activity against the 2 targets, so that if you have a mutation in one, you still have activity,” Hooton said. Gepotidacin was “not inferior to nitrofurantoin, and in fact, superior in one of the two trials.” He noted that both gepotidacin and sulopenem trials followed “the new FDA guidance [requiring] complete resolution of symptoms and a reduction in [urinary] CFU [colony-forming units],” which lowered reported success rates. “That’s a problem; the cure rates look abysmally low. But that’s just an artifact of the FDA requirement for that stringent outcome,” he said. Haumschild emphasized that trial design nuances are critical for interpreting real-world relevance.

Although promising, Fromer cautioned that resistance is inevitable: “These are drugs that patients in the US haven’t seen, so we are expecting the organisms to be susceptible…but history tends to repeat itself.” She recalled early enthusiasm for fluoroquinolones: “Everybody thought it was the greatest thing since sliced bread…and then what happened? Resistance rates…. It doesn’t take long for resistance to occur.” Fromer noted that sulopenem “is really not a great option to treat empiric, uncomplicated UTIs” but offers value in resistant ESBL cases: “I send at least 5 or 6 patients a month to the infusion center for [intravenous] ertapenem [Invanz]. Sulopenem does take that burden off…. I see that as a big win for that population.” Despite future resistance concerns, she concluded, “having these options available dilutes the impact of resistance.” Haumschild added, “Maybe these therapies aren’t going to be practice changing for empiric therapy. But maybe they’re practice changing for later lines of therapy” and could reduce care barriers.

Balancing Affordability and Effectiveness

Despite the availability of low-cost antibiotics, Cheng cautioned that treatment failure and recurrence remain major concerns: “The antibiotics that we have currently are generally effective, but the treatment failure rate is still considerable, [approximately] 17% nationally.” Many physicians are “not excited about the current treatments, [and] more often than not, we’re not targeting the microorganism with the appropriate antibiotic,” leading to recurrence and increased resistance that “exacerbates a much larger public health problem.” She argued, “The decision is more than about which drug is more affordable…. Rather, it should be about how best we can target our treatment more appropriately, so we avoid long-term costs and large-scale impacts,” recommending susceptibility testing, local antibiograms, and patient-specific risk factors.

On payer-related barriers, Haumschild explained, “Patients with a history of treatment failure are at risk of subsequent treatment failure and recurrence…[so] following the traditional course of therapies would not be the most suitable. [Yet] there is not sufficient awareness among payers that the patient’s medical history could compromise antibiotic effectiveness. I can see there being potential barriers in the reimbursement of new emerging treatments.” He added, “Payers are trying to steward costs but we’ve got to advocate when appropriate and walk that fine line of meeting the prior authorization criteria.”

Murray stressed that with new therapies, “the importance really comes [from] making sure that we, as a community, come together and determine what patient population this is going to be most important [for].” She urged clinicians to “buckle down and advocate and jump through those hoops with the prior authorization” for patients with limited options: “Not the brand new patient [but] repetitive patients in our practices.” Acknowledging that the process is “quite frustrating,” she added, “Really homing in on the correct population takes a little bit of that burden off.”

Key Takeaways

Antibiotic resistance remains a pressing concern, with trends pointing toward an “incessant rise” that could outpace drug development, Hooton warned. Although new agents such as gepotidacin offer hope, he said, “It’s just going to be a race that’s very difficult to win,” especially as “companies are not coming up with new products; there’s no money in it.” He stressed stewardship and guideline adherence. “We know that a lot of people don’t read guidelines; just look at the fluoroquinolone continued use for simple cystitis—it’s just crazy.” He highlighted vaccines and “small molecules that inhibit the attachment of E coli to the epithelium” as promising nonantibiotic strategies.

Cheng echoed these concerns, calling uncomplicated UTIs “a brewing ground for resistance if antibiotics are not prescribed carefully and appropriately.” She emphasized that “understanding the local resistance levels and risk factors for treatment failure is so essential” and called for nuance in payer decisions: “Antibiotic prescription is not a one-size-fits-all for everybody, for all regions, and even among people within a region.” Although resistance is inevitable, “newer antibiotics may be promising and cost-effective alternatives…especially if they could curb downstream complications and the bigger issue of resistance at the public health level.”

Murray emphasized collaboration and education: “We’re on the same team with the patient. It is ensuring that we’re treating the patients [who] need to be treated, [helping them understand that getting a urine sample] isn’t because you’re against them, but [that] it is the big picture, and it helps them in the long run.” She stressed, “When they get that understanding, it really tends to make sense, and it saves time, money, visits, etc, in the long term.”

Fromer underscored the need for clinician education, noting that prescribing issues often stem from colleagues: “The practitioners we work with [are] the source of a lot of the problems that we’re seeing.” She explained, “Education doesn’t always happen by somebody going and finding the guideline…. I trek around to ob-gyn grand rounds, internal medicine and geriatrics, and I give the same talk over and over.” She also gives patients handouts explaining “why we need a urine culture, what our antibiotic courses are, why you have a UTI, how can you prevent UTI, listing everything from cranberry supplements to D-mannose, to methenamine…. [It’s] a grassroots effort to alleviate this burden on the patients, on the health care system, and, frankly, on [those of] us who are taking care of these patients.” •

References

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11. Anger J, Lee U, Ackerman AL, et al. Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline. J Urol. 2019;202(2):282-289. doi:10.1097/JU.0000000000000296

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13. Blujepa (gepotidacin) approved by US FDA for treatment of uncomplicated urinary tract infections (uUTIs) in female adults and paediatric patients 12 years of age and older. News release.GSK. March 25, 2025. Accessed April 3, 2025. https://www.gsk.com/en-gb/media/press-releases/blujepa-gepotidacin-approved-by-us-fda-for-treatment-of-uncomplicated-urinary-tract-infections/

14. FDA approves new treatment for uncomplicated urinary tract infections. News release. FDA. Updated April 29, 2024. Accessed April 4, 2025. https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-uncomplicated-urinary-tract-infections

15. FDA approves new treatment for uncomplicated urinary tract infections in adult women who have limited or no alternative oral antibiotic treatment options. News release. FDA. October 24, 2024. Accessed April 3, 2025. https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-new-treatment-uncomplicated-urinary-tract-infections-adult-women-who-have-limited-or-no

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17. Orlynvah. Prescribing information. Iterum Therapeutics US Limited; 2024. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/213972s000lbl.pdf

18. Pivya. Prescribing information. Utility Therapeutics, Inc; 2024. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/216483s000lbl.pdf