What is the recommended treatment for uncomplicated cystitis?

Treatment of Uncomplicated Cystitis

Nitrofurantoin (100 mg twice daily for 5 days) is the first-line treatment for uncomplicated cystitis due to minimal resistance patterns and limited collateral damage. 1

First-Line Treatment Options

The American College of Physicians recommends the following first-line treatments for uncomplicated cystitis:

1. Nitrofurantoin: 100 mg twice daily for 5 days

   • Advantages: Minimal resistance patterns, limited collateral damage
   • Contraindication: Should not be used in patients with significant renal impairment (creatinine clearance <30 mL/min), pregnant women in third trimester, or patients with G6PD deficiency 1

2. Trimethoprim-sulfamethoxazole (TMP-SMX): 160/800 mg (one double-strength tablet) twice daily for 3 days

   • Use when local resistance rates are <20% or when the infecting strain is known to be susceptible
   • FDA-approved for urinary tract infections due to susceptible strains of E. coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris 2, 3
   • Note: FDA label states that initial episodes of uncomplicated UTIs should be treated with a single effective antibacterial agent rather than the combination 2, 3

3. Fosfomycin trometamol: 3 g single dose

   • Advantages: Minimal resistance and limited collateral damage
   • Limitation: Potentially inferior efficacy compared to standard short-course regimens 1

Second-Line Treatment Options

When first-line agents cannot be used:

1. Fluoroquinolones (ofloxacin, ciprofloxacin, levofloxacin): 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. β-Lactam agents (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil): 3-7 days

   • Generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials 1
   • Should only be used when other recommended agents cannot be used

Treatment Algorithm

1. Assess patient factors:

   • Renal function (avoid nitrofurantoin if CrCl <30 mL/min)
   • Pregnancy status (avoid nitrofurantoin in third trimester)
   • G6PD status (avoid nitrofurantoin if deficient)
   • Local resistance patterns (avoid TMP-SMX if local E. coli resistance >20%)

2. Select appropriate antibiotic:

   • If no contraindications: Nitrofurantoin 100 mg twice daily for 5 days
   • If nitrofurantoin contraindicated and local TMP-SMX resistance <20%: TMP-SMX 160/800 mg twice daily for 3 days
   • If both contraindicated: Fosfomycin 3 g single dose
   • If all first-line options contraindicated: Consider fluoroquinolones or β-lactams

3. Monitor response:

   • If symptoms don't improve within 72 hours, obtain urine culture and consider alternative antibiotics 1
   • No routine post-treatment urinalysis or cultures are needed if symptoms resolve 1

Special Considerations

• Diagnosis: Can be made with high probability based on focused history of lower urinary tract symptoms (dysuria, frequency, urgency) and absence of vaginal discharge 1, 4
• Urine testing: Urinalysis provides minimal diagnostic benefit in patients with typical symptoms; dipstick testing can help confirm diagnosis when symptoms are unclear 1, 4
• Urine culture: Recommended in suspected pyelonephritis, symptoms that don't resolve or recur within 4 weeks after treatment, women with atypical symptoms, and pregnant women 1, 4
• Recurrent cystitis: Consider patient self-initiated therapy with a short course of antibiotics at symptom onset for women with recurrent uncomplicated cystitis 5
• Antibiotic resistance: Avoid amoxicillin or ampicillin for empirical treatment due to poor efficacy and high worldwide resistance rates 1

Common Pitfalls to Avoid

• Using fluoroquinolones as first-line therapy (reserve for more serious infections)
• Failing to adjust antibiotic choice based on renal function
• Prescribing nitrofurantoin to patients with CrCl <30 mL/min
• Treating asymptomatic bacteriuria in non-pregnant women (promotes antimicrobial resistance without clinical benefit) 1
• Using prolonged antibiotic courses when short courses are equally effective
• Not reassessing patients who fail to improve within 72 hours

By following these evidence-based recommendations, clinicians can effectively treat uncomplicated cystitis while minimizing antibiotic resistance and adverse effects.