What are the treatment options for cystitis (inflammation of the bladder)?

From the Guidelines

The most effective treatment for cystitis is nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) due to its minimal resistance and efficacy comparable to other treatments, as recommended by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases 1.

Treatment Options

The treatment options for cystitis include:

• Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days)
• Trimethoprim-sulfamethoxazole (160/800 mg [1 double-strength tablet] twice-daily for 3 days)
• Fosfomycin trometamol (3 g in a single dose)
• Pivmecillinam (400 mg bid for 3–7 days)

Considerations

When choosing a treatment, it is essential to consider the local antimicrobial resistance patterns, particularly for Escherichia coli, which is the most common cause of uncomplicated cystitis 1.

• The resistance rates for antimicrobials vary by region and country, and active surveillance studies can help inform empirical antimicrobial selection.
• The use of individual-level predictors of resistance, such as recent travel or previous antibiotic use, can also be helpful in guiding treatment decisions.

Alternative Treatments

Alternative treatments, such as fluoroquinolones, may be considered when other options are not suitable, but their use should be restricted due to concerns about promoting resistance and increasing the risk of MRSA 1.

Duration of Treatment

The duration of treatment for cystitis is typically 3-7 days, and the shortest effective course should be used to minimize the risk of resistance and adverse effects 1.

Key Points

• Nitrofurantoin monohydrate/macrocrystals is a first-line treatment option for cystitis due to its efficacy and minimal resistance.
• Local antimicrobial resistance patterns and individual-level predictors of resistance should be considered when choosing a treatment.
• Alternative treatments, such as fluoroquinolones, should be used judiciously due to concerns about resistance and adverse effects.

From the Research

Treatment Options for Cystitis

The treatment options for cystitis, or inflammation of the bladder, vary depending on the severity and cause of the infection.

• First-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females includes:
  • A 5-day course of nitrofurantoin 2
  • A 3-g single dose of fosfomycin tromethamine 2, 3
  • A 5-day course of pivmecillinam 2, 3
• Second-line options include:
  • Oral cephalosporins such as cephalexin or cefixime 2
  • Fluoroquinolones and β-lactams, such as amoxicillin-clavulanate 2
• For UTIs due to AmpC- β-lactamase-producing Enterobacteriales, treatment options include:
  • Nitrofurantoin, fosfomycin, pivmecillinam, fluoroquinolones, cefepime, piperacillin-tazobactam, and carbapenems 2
• For UTIs due to ESBLs-E coli, treatment oral options include:
  • Nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 2
• Parenteral treatment options for UTIs due to ESBLs-producing Enterobacteriales include:
  • Piperacillin-tazobactam, carbapenems, ceftazidime-avibactam, ceftolozane-tazobactam, aminoglycosides, and fosfomycin 2

Special Considerations

• In men, acute bacterial prostatitis is typically treated with antibiotic therapy, while chronic bacterial prostatitis requires prolonged antibiotic therapy 4
• In women with diabetes, treatment for acute cystitis is similar to that for women without diabetes 3
• Increasing resistance rates among uropathogens have complicated treatment of acute cystitis, and individualized assessment of risk factors for resistance and regimen tolerability is needed to choose the optimum empirical regimen 2, 3