A pragmatic Lancet RCT (SCOUT) reshapes UTI management. In 768 women, nitrofurantoin achieved the highest clinical resolution at day 7 (74%) vs single-dose fosfomycin (59%), with a significant 15.5% absolute difference. Pivmecillinam and two-dose fosfomycin performed intermediately. Adverse events were mild across groups.

The message is clear: convenience may cost efficacy. Short-course regimens—especially nitrofurantoin—should be preferred over single-dose fosfomycin. A timely reminder that in antimicrobial stewardship, simplicity must not trump success