The 5 best antibiotics for UTI. Take this, not that!

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What are the best antibiotics for your urinary tract infection (UTI)? When you are sick with a UTI, you need a quick and effective treatment and this will often mean a course of antibiotics.

Sometimes you are so overwhelmed with UTI symptoms, that you’ll take any antibiotic you can get. However, it is important to be careful and informed about the different treatment options.

First, are antibiotics necessary?

Taking antibiotics should not be treated lightly, especially given the increased risk of developing multi-drug resistant bacteria like ESBL E.coli, for which we are running out of treatments.

  • While burning when you pee and the urge to urinate, are common UTI symptoms, they are not always indicative of a urinary tract infection.
  • Antibiotics alone are not as effective against mature bacterial biofilms.
  • An incomplete course or prophylactic antibiotics can actually promote the growth of bacterial biofilms.
  • Antioxidants, available in N-acetylcysteine (NAC) supplements can increase the effectiveness of antibiotics and help you fight mature bacterial biofilms.
  • Natural supplements like D-Mannose can be effective at the first sign of a UTI and don’t come with the extensive side effect profile of many antibiotics

Therefore, you and your physician should ensure that necessary testing is done before prescribing antibiotics. This includes analyzing accurate local antibiotic resistance data to make sure you get the best empirical (best guess) antibiotics until more data is available.

Accurate Diagnosing of a UTI

Can you self-diagnose a UTI? First of all, read why OTC UTI test strips could be inaccurate in your case.

Moreover, in a recent study, less than 50% of women who reported UTI symptoms to their physician truly had a urinary tract infection.

The most accurate predictors of a true UTI are the combination of urgency to urinate, burning during urination, and pyuria (or white blood cell, a sign of inflammation or infection, in the urine sample).

The same study suggests that more physicians should perform wet mount microscopy test (looking at the urine under the microscope, which is more accurate than the urine dipstick test) to look for white cells in the urine before prescribing antibiotics for UTI.

Have you noticed blood in your urine, cloudy urine or a “funny” smell to your urine? These are some symptoms that are indicative of a UTI, especially if they have been happening only for a short time. These symptoms may be more predictive than lower abdomen pain and burning with urination, which is also common with bladder inflammation that is not due to a UTI.

Important: if you have recurring blood in your urine and no other signs of a UTI, let your doctor know right away as this could be a sign of a bladder tumor that should be treated right away.

Therefore, whenever you are offered antibiotics for UTI, always ask for a urine culture test or wet mount microscopy test.

Always pay attention to your UTI symptoms, even after you finish your antibiotic treatment. If you have just finished a course of antibiotics but your symptoms still linger on, read this interview with a urologist explaining why antibiotics may not work for your UTI.

Best antibiotics for UTI treatment

According to International clinical guidelines on how to treat UTI, these are the best antibiotics for UTI. I have listed them in preference order according to the guidelines.

If you do not recognize some of the names on the list, it may be because some of these drugs are available in the EU, but not in the USA.

This list is only applicable to otherwise healthy and non-pregnant adults.


Brand names: Macrobid, Nitrofurantoin, Furadantin, Furalan, Macrodantin.

This is my favorite antibiotic for UTI treatment because it has the least impact on gut flora. Still, if you are taking Macrobid for UTI, check out my post on the pros and cons of nitrofurantoin. This antibiotic works best for UTIs caused by E. coli bacteria.

2. Trimethoprim-sulfamethoxazole.

Brand names: Septra, Bactrim, Sulfatrim.

This antibiotic is becoming less popular due to E. coli’s increasing resistance to it. In some studies, more than 34% of women diagnosed with a UTI had E. coli bacteria resistant to this group of antibiotics. However, it is still an excellent choice if you know that your bacteria are sensitive to it (and you are not allergic) as it is a (relatively) safe antibiotic.

3. Fosfomycin trometamol

Brand name: Monurol.

A single oral dose of fosfomycin trometamol, 3 g (the approved dosage), get highly concentrated in the urine. Results of recent randomized trials show that single-dose was enough to treat an uncomplicated UTI (compared to 3 to 7-day courses of ciprofloxacin, norfloxacin, cotrimoxazole or nitrofurantoin) in women.

This antibiotic works well for most bacteria causing UTI and has not been contributing to antibiotic resistance. It’s an excellent choice if you have had multiple drug-resistant UTIs and can’t seem to find an antibiotic that will work.

4. Pivmecillinam

Brand names: AlexidDysedinPenomaxMelysin, Selexid, RelexidEmcil, Pivicil.

Pivmecillinam is an oral antibiotic with excellent clinical efficacy in the treatment of uncomplicated UTIs. It is commonly used in  Nordic countries with few problems, but other physicians may be less familiar with it. In a recent clinical study, it effectively treated UTIs caused by E. coli resistant to resistant to popular antibiotics, like fluoroquinolones. It’s important to know that this antibiotic slows down bacterial growth but does not necessarily kill all the bacteria. While this may be ok in the short term, it is possible that persistent low amount of UTI causing bacteria in the urine may put you at risk for future UTIs. This antibiotic also has minimal impact on your gut’s microbiota

5. Fluoroquinolones, ofloxacin, ciprofloxacin, and levofloxacin.

Brand names: Cetraxal, Cipro, Ciloxan. Update from 08/2016: read this update on Cipro from FDA.

Even though this antibiotic is still on the list of best antibiotics for UTI, it is no longer recommended for an initial uncomplicated UTI due to a plethora of serious side effects like tendinitis, tendon rupture, and peripheral neuropathy, especially if you are older than 60 years.

Do not accept Cipro as a prescription for an uncomplicated UTI and get familiar with the dangers of using Cipro. Ask your physician for alternatives (including anything from the list above).

Note: Amoxicillin and ampicillin are considered but not recommended. Also, read about Cefdinir for UTI and why it is not included in the Top 5 best antibiotics for UTI.

Antibiotics for UTI Caused by ESBL E. coli

Unfortunately, more and more patients are diagnosed with a UTI caused by extended-spectrum beta-lactamase (ESBL)-producing E. coli. These are E. coli that have evolved to find ways to evade the antibiotics that normally would kill them. In this case, your UTI will most likely be resistant to many of first-line antibiotics listed above and you have a higher risk of developing a kidney infection. At risk group includes:

  • Users of urinary catheters
  • Patients with recurrent UTIs
  • Patients with recent exposure to antibiotics.

Antibiotics classified as carbapenems (mipenem, meropenem, doripenem, and ertapenem) are often the drug of choice when treating UTIs caused by ESBL-producing bacteria. Antimicrobials, such as nitrofurantoin, fosfomycin, amikacin, and cefepime, may also be an option.

There are also new beta-lactam/ beta-lactamase inhibitor combinations that came to the market in the United States in the past few years, that are effective against carbapenem-resistant Enterobacteriaceae (CRE) and multidrug-resistant Pseudomonas aeruginosa (two very resistant bugs).

  • Ceftazidime-avibactam (Avycaz), active against a variety of multidrug-resistant Gram-negative bacteria, but not Gram-positive organisms.
  • Ceftolozane-tazobactam (Zerbaxa), active against a number of multidrug-resistant Gram-negative bacteria.
  • Meropenem-vaborbactam (Vabomere), for  multidrug-resistant Gram-negative bacteria.

Be aware that all of these antibiotics are given intravenously, meaning you will either need to be hospitalized or have a PICC line (a semi-permanent IV) placed. They are quite heavy duty antibiotics and will likely have a long-lasting effect on your gut and vaginal flora as well.

Bacterial biofilms and antibiotics

Have you heard about bacterial biofilms? While you may not have heard of this persistent community of bacteria, they could be to blame for your recurrent infections and your UTI’s resistance to antibiotics.

Check out this post about bacterial biofilms and their interaction with antibiotics.

OTC products to supplement antibiotics for UTI

When starting an antibiotic treatment consider using D-Mannose and special probiotics to speed up recovery and prevent your UTIs from recurring.

D-Mannose will help you to flush the bacteria from your bladder, while vaginal probiotics will maintain the good bacteria and help to prevent future infections. Read this post if you are not familiar with D-Mannose supplement.

So, which antibiotics did your physician prescribe for you? Please tell us about your experience in the comments below—and remember to let me know which country you are from.

Also, read an updated post about antibiotics for UTI by Dr. Steinberg.

Written by Anastasia Visotsky,

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