What is the recommended treatment for uncomplicated cystitis?

Treatment of Uncomplicated Cystitis

First-line treatment options for uncomplicated cystitis include nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days), trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), and fosfomycin trometamol (3 g single dose). 1

First-Line Treatment Options

The Infectious Diseases Society of America (IDSA), American College of Physicians (ACP), and European Urology guidelines recommend the following first-line treatments for uncomplicated cystitis:

1. Nitrofurantoin monohydrate/macrocrystals

   • Dosage: 100 mg twice daily
   • Duration: 5 days
   • Advantages: Low resistance rates, minimal collateral damage to gut flora

2. Trimethoprim-sulfamethoxazole (TMP-SMX)

   • Dosage: 160/800 mg (one double-strength tablet) twice daily
   • Duration: 3 days
   • Note: Should be used only in regions where E. coli resistance is less than 20% 1, 2
   • FDA-approved for urinary tract infections due to susceptible strains of E. coli, Klebsiella, Enterobacter, Morganella morganii, Proteus mirabilis, and Proteus vulgaris 3, 4

3. Fosfomycin trometamol

   • Dosage: 3 g
   • Duration: Single dose
   • Advantages: Convenient dosing, good compliance 1

Alternative Treatment Options

When first-line agents cannot be used, consider these alternatives:

1. Beta-lactam antibiotics

   • Options: Amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil
   • Note: These have inferior efficacy and more adverse effects compared to first-line agents 1

2. Fluoroquinolones

   • Should be reserved as alternative options due to risk of adverse effects and concerns about resistance 1
   • Not recommended for initial treatment due to ecological concerns and safety issues 5

3. Cephalosporins

   • Options: Cefpodoxime (200 mg twice daily for 10 days) or ceftibuten (400 mg once daily for 10 days)
   • Can be used if the patient doesn't have a history of anaphylaxis to penicillin 1

Treatment Duration

Short-course therapy is as effective as longer treatment for uncomplicated UTIs, with fewer adverse events:

• Nitrofurantoin: 5 days
• TMP-SMX: 3 days
• Fosfomycin: single dose 1, 6

Special Considerations

Recurrent Cystitis

For patients with recurrent cystitis (≥4 episodes per year):

• Consider prophylactic antibiotics if non-antimicrobial measures fail
• Options include nitrofurantoin 50-100 mg daily or trimethoprim 100 mg daily 1, 7
• Post-coital single dose when UTIs are related to sexual activity 7

Non-Antimicrobial Measures

• Increase fluid intake
• Urinate after intercourse if UTIs are related to sexual activity
• Cranberry juice has modest efficacy in reducing frequency of episodes 1, 7

Follow-up Recommendations

• No post-treatment urinalysis or urine culture is required if symptoms resolve
• If symptoms do not resolve or recur within 2 weeks, obtain a urine culture and antibiogram, and consider treatment with another agent for 7 days 1
• Urine cultures are recommended in:
  • Suspected pyelonephritis
  • Symptoms that don't resolve or recur within 4 weeks after treatment
  • Women with atypical symptoms
  • Pregnant women 1, 2

Common Pitfalls to Avoid

1. Overuse of fluoroquinolones: Despite their effectiveness, fluoroquinolones should be reserved due to safety concerns and increasing resistance 1, 5

2. Inappropriate treatment duration: Longer treatment durations than recommended are common in clinical practice but unnecessary and may contribute to resistance 1

3. Failure to consider local resistance patterns: For TMP-SMX, consider local E. coli resistance patterns before prescribing 1, 2

4. Routine urine cultures: Not needed for uncomplicated cystitis but should be obtained in specific situations as mentioned above 1, 2

5. Ignoring ecological impact: Consider antibiotics with minimal collateral damage to gut flora, such as nitrofurans, which are classified in the WHO ACCESS group as agents with minimal collateral effect 5