What is the recommended treatment for uncomplicated cystitis?

Treatment of Uncomplicated Cystitis

For uncomplicated cystitis, nitrofurantoin (100 mg twice daily for 5 days) is the recommended first-line treatment due to its minimal resistance patterns and limited collateral damage, with efficacy comparable to trimethoprim-sulfamethoxazole. 1

First-Line Treatment Options

1. Nitrofurantoin monohydrate/macrocrystals

   • Dosage: 100 mg twice daily for 5 days
   • Advantages: Minimal resistance, limited collateral damage to normal flora
   • Contraindications: Not for use in patients with CrCl <30 mL/min, third trimester pregnancy, or G6PD deficiency 2

2. Trimethoprim-sulfamethoxazole (TMP-SMX)

   • Dosage: 160/800 mg (one double-strength tablet) twice daily for 3 days
   • Only appropriate when local resistance rates are <20% or when the infecting strain is known to be susceptible 1
   • FDA-approved for UTIs caused by E. coli, Klebsiella, Enterobacter, Morganella morganii, and Proteus species 3, 4

3. Fosfomycin trometamol

   • Dosage: 3 g single dose
   • Advantages: Minimal resistance, limited collateral damage
   • Note: May have inferior efficacy compared to standard short-course regimens 1

Second-Line Treatment Options

1. Fluoroquinolones (ofloxacin, ciprofloxacin, levofloxacin)

   • Highly efficacious in 3-day regimens
   • Should be reserved for important uses other than uncomplicated cystitis due to:
     • Propensity for collateral damage to normal flora
     • FDA warnings about serious side effects
     • Need to preserve effectiveness for more serious infections 1, 2

2. β-Lactam agents (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil)

   • Use for 3-7 days when other recommended agents cannot be used
   • Generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials 1

Inappropriate Treatments

• Amoxicillin or ampicillin should not be used for empirical treatment due to poor efficacy and high worldwide resistance rates 1

Diagnostic Approach

• Diagnosis can be made with high probability based on focused history of lower urinary tract symptoms (dysuria, frequency, urgency) and absence of vaginal discharge 2, 5
• Urinalysis (dipstick) provides minimal diagnostic benefit in patients with typical symptoms but can help confirm diagnosis when symptoms are unclear 2
• Urine culture is not routinely needed for uncomplicated cystitis but should be obtained in:
  • Suspected pyelonephritis
  • Symptoms that don't resolve or recur within 4 weeks after treatment
  • Women with atypical symptoms
  • Pregnant women 2, 5

Special Considerations

• Local resistance patterns: Monitor local resistance patterns for TMP-SMX, which approaches 18-22% in some US regions, while resistance to nitrofurantoin remains low at approximately 2% 2
• Recurrent cystitis: For women with recurrent UTIs, self-initiated short-course therapy at symptom onset is an effective strategy that minimizes antibiotic exposure 6
• Pregnancy: Pregnant women should be screened for and treated for asymptomatic bacteriuria with standard short-course treatment or single-dose fosfomycin 2
• Breastfeeding: Nitrofurantoin is safe during lactation 2

Follow-up

• No routine post-treatment urinalysis or cultures are needed if symptoms resolve 2
• If symptoms don't improve within 72 hours, reevaluate with urine culture and consider alternative antibiotics based on susceptibility 2

Prevention of Recurrence

• Postmenopausal women may benefit from vaginal estrogen replacement
• Premenopausal women may benefit from increased fluid intake
• Avoid treating asymptomatic bacteriuria in non-pregnant women as it promotes antimicrobial resistance without clinical benefit 2