What is the recommended initial treatment for cystitis in older women?

Treatment of Cystitis in Older Women

For uncomplicated cystitis in older women, nitrofurantoin (5-day course) is the recommended first-line treatment, with trimethoprim-sulfamethoxazole (3-day course) as an alternative when local resistance is less than 20%. 1

Diagnostic Considerations

Before initiating treatment, it's important to distinguish true UTI from asymptomatic bacteriuria, which is common in older women but should not be treated:

• True UTI diagnostic criteria:

  • Recent onset of dysuria, frequency, or incontinence
  • Costovertebral angle pain/tenderness
  • Systemic symptoms (fever >37.8°C, rigors, delirium)
  • Significant pyuria (≥10 WBC/mm³ or ≥5 WBC/HPF)
  • Positive urine culture (>100,000 organisms/mL) 1

• Warning: Treating asymptomatic bacteriuria in elderly women does not improve outcomes and increases antibiotic resistance and adverse effects 1

First-Line Treatment Options

1. Nitrofurantoin (5-day course)

   • Preferred first-line option for uncomplicated cystitis
   • High susceptibility rates against common pathogens, including ESBL-producing organisms
   • Contraindicated in patients with CrCl <30 mL/min 1

2. Trimethoprim-sulfamethoxazole (3-day course)

   • Alternative when local resistance <20%
   • 3-day course is as effective as longer treatment durations while minimizing adverse effects 1, 2

3. Fosfomycin (single dose)

   • Alternative first-line option
   • Particularly useful when other options are contraindicated 1, 2

Second-Line Options

1. Beta-lactams (5-7 days)

   • Second- or third-generation oral cephalosporins or pivmecillinam
   • Use when first-line options are contraindicated or resistance is suspected
   • Note: Beta-lactams are generally less effective than other options and require longer treatment duration (≥5 days) 1, 3

2. Fluoroquinolones (e.g., ciprofloxacin)

   • Should be used only if susceptibility is confirmed by culture
   • Avoid in elderly patients with significant renal impairment
   • Caution: FDA warnings about serious safety issues, including tendon, muscle, joint, nerve, and central nervous system effects 1

Treatment Duration Considerations

• Single-dose therapy is generally less effective than 3-day or longer courses for elderly women 4
• 3-day courses are typically as effective as longer courses for trimethoprim-sulfamethoxazole while minimizing adverse effects 3, 4
• Beta-lactams require longer treatment duration (≥5 days) for optimal efficacy 3
• Evidence suggests that short-course treatment (3-6 days) may be sufficient for uncomplicated UTIs in elderly women 4

Special Considerations for Postmenopausal Women

• Vaginal estrogen replacement should be considered for postmenopausal women with recurrent UTIs, as it reduces UTI risk by 30-50% 1
• Adequate hydration and proper hygiene are important preventive measures 1

Common Pitfalls to Avoid

1. Treating asymptomatic bacteriuria - common in older women but should not be treated with antibiotics 1
2. Using fluoroquinolones as first-line therapy - associated with increased resistance and adverse effects 1
3. Inadequate treatment duration - single-dose therapy (except for fosfomycin) is generally less effective in older women 4
4. Failing to adjust dosing for renal function - especially important in elderly patients 1
5. Not considering local resistance patterns - particularly for trimethoprim-sulfamethoxazole 1, 2

When to Consider Urine Culture

• Women with suspected pyelonephritis
• Symptoms that do not resolve or recur within 2-4 weeks after treatment
• Atypical presentation
• Recurrent infections
• Complicated UTI risk factors 2

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