What is the treatment for chronic cystitis?

Treatment for Chronic Cystitis

First-line treatment for chronic cystitis includes nitrofurantoin (100 mg twice daily for 5 days), fosfomycin trometamol (3 g single dose), or trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) if local resistance is <20%. 1

First-Line Treatment Options

• Nitrofurantoin: 100 mg twice daily for 5 days

  • Preferred due to minimal resistance and high efficacy against E. coli
  • Recommended by multiple guidelines including the American Urological Association and American College of Physicians 1

• Fosfomycin trometamol: 3 g single dose

  • Offers convenience of one-time dosing
  • Appropriate choice due to minimal resistance and low propensity for collateral damage
  • May have slightly inferior efficacy compared to standard short-course regimens 2, 1

• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days

  • Use only in regions where E. coli resistance is <20%
  • Traditional first-line agent but rising resistance rates necessitate caution 2, 1

Alternative Treatment Options

• Pivmecillinam: 400 mg three times daily for 3-5 days

  • Recommended in regions where available (primarily European countries) 2, 1

• β-Lactam agents: 3-7 day regimens

  • Including amoxicillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil
  • Use only when first-line agents cannot be used
  • Generally have inferior efficacy and more adverse effects 2

• Fluoroquinolones: 3-day regimens

  • Highly efficacious but should be reserved for important uses other than acute cystitis
  • Not recommended as first-line due to propensity for collateral damage and FDA warnings about serious side effects 2, 1

Special Considerations for Chronic/Recurrent Cases

• Intravesical therapy: Hyaluronic acid and chondroitin sulfate

  • Shown to be effective in reducing recurrent episodes
  • Research indicates 72.7% of patients treated with HA-CS remained event-free at follow-up compared to only 30.4% with antibiotic therapy alone 3
  • Works by improving urothelium thickness and reducing bacterial load

• For interstitial cystitis (a form of chronic cystitis):

  • Oral treatments include pentosan polysulfate, tricyclic antidepressants, and antihistamines
  • Intravesicular therapies include hydrodistention, dimethyl sulfoxide, and heparin 4

Treatment Duration and Follow-Up

• Clinical improvement should occur within 48-72 hours of starting appropriate treatment
• No routine post-treatment urinalysis or urine cultures needed if symptoms resolve
• If symptoms persist beyond 72 hours or recur within 2 weeks:
  • Obtain urine culture with susceptibility testing
  • Adjust therapy accordingly
  • Consider a 7-day regimen using another agent 1

Important Cautions

• Avoid amoxicillin or ampicillin for empirical treatment due to poor efficacy and high prevalence of antimicrobial resistance 2, 5

• Consider ecological safety of antimicrobial therapy:

  • WHO classifies nitrofurantoin and furazidine in the ACCESS group (minimal collateral effect)
  • Fosfomycin and cephalosporins are in the WATCH group 5

• Monitor local resistance patterns:

  • TMP-SMX resistance now approaches 18-22% in some regions of the US
  • Resistance to nitrofurantoin and fluoroquinolones has remained low at approximately 2% 6

For patients with truly recurrent cystitis that does not respond to standard antimicrobial therapy, consider referral to a urologist for further evaluation and specialized treatment options.