What is the treatment for cystitis?

Treatment of Cystitis

For uncomplicated cystitis in women, nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is the recommended first-line treatment due to its high efficacy and low resistance rates. 1

First-Line Treatment Options

1. Nitrofurantoin monohydrate/macrocrystals

   • Dosage: 100 mg twice daily for 5 days
   • Efficacy: 90% clinical cure rate, 92% bacterial eradication rate 1
   • Advantages: Minimal resistance (approximately 2%) and minimal collateral damage 2, 1

2. Trimethoprim-sulfamethoxazole (TMP-SMX)

   • Dosage: 160/800 mg (double-strength tablet) twice daily for 3 days
   • Use only if:
     • Local resistance rates of uropathogens <20%
     • Not used in previous 3 months
     • Infecting strain is known to be susceptible 2, 1

3. Fosfomycin trometamol

   • Dosage: 3 g single dose
   • Note: May have inferior efficacy compared to standard short-course regimens 2

Alternative Treatment Options

When first-line agents cannot be used, consider:

1. Fluoroquinolones (e.g., ciprofloxacin)

   • While highly efficacious, should be reserved for more serious infections due to:
     • Propensity for collateral damage to normal flora
     • FDA warnings about serious side effects
     • Need to preserve for more serious infections 2, 1
   • Use only if fluoroquinolone resistance <10% 1

2. β-Lactam agents

   • Options: amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil (3-7 days)
   • Generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials 2
   • Should be used only when other recommended agents cannot be used 2

Diagnostic Considerations

• Urinalysis (dipstick test) to check for indicators of infection
• 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 1

Monitoring and Follow-up

• No routine post-treatment urinalysis or cultures needed if symptoms resolve 1
• If symptoms don't improve within 72 hours, reevaluate with urine culture 1

Special Populations

Pregnant Women

• Screen for and treat asymptomatic bacteriuria
• Consider single-dose fosfomycin or standard short-course treatment 1

Postmenopausal Women

• May benefit from vaginal estrogen replacement
• Consider continuous antimicrobial prophylaxis when non-antimicrobial measures have been unsuccessful 1

Patients with Renal Impairment

• Nitrofurantoin is contraindicated in patients with creatinine clearance <30 mL/min 1
• Fluoroquinolones should be used with caution in patients with GFR <50 mL/min 1
• Extended treatment duration (7-14 days) may be needed 1

Common Pitfalls to Avoid

1. Using fluoroquinolones as first-line therapy despite recommendations to reserve them for more serious infections
2. Prescribing TMP-SMX in areas with high resistance rates (>20%)
3. Not adjusting therapy for patients with renal impairment
4. Treating asymptomatic bacteriuria (except in pregnant women)
5. Performing routine post-treatment cultures in patients whose symptoms have resolved

The treatment of cystitis should be guided by local resistance patterns, patient-specific factors, and antimicrobial stewardship principles to ensure optimal outcomes while minimizing adverse effects and antimicrobial resistance.