What is the recommended treatment for cystitis vs urinary tract infection (UTI)?

Treatment of Cystitis vs Urinary Tract Infection (UTI)

For uncomplicated cystitis in women, first-line treatment includes fosfomycin trometamol 3g single dose, nitrofurantoin 100mg twice daily for 5 days, or pivmecillinam 400mg three times daily for 3-5 days, while broader UTIs like pyelonephritis require longer treatment with fluoroquinolones (5-7 days) or trimethoprim-sulfamethoxazole (14 days). 1

Understanding the Difference

Cystitis is a specific type of UTI limited to the bladder, while UTI is a broader term that can include infections of any part of the urinary tract:

• Uncomplicated cystitis: Infection limited to the bladder in non-pregnant women with no anatomical or functional abnormalities
• Broader UTIs: Include pyelonephritis (kidney infection) and complicated UTIs (those with structural abnormalities or in special populations)

Treatment Algorithm for Uncomplicated Cystitis in Women

First-line options:

• Fosfomycin trometamol: 3g single dose 1, 2
• Nitrofurantoin: 100mg twice daily for 5 days or 50-100mg four times daily for 5 days 1
• Pivmecillinam: 400mg three times daily for 3-5 days 1

Alternative options (when first-line not appropriate):

• Cephalosporins (e.g., cefadroxil): 500mg twice daily for 3 days (if local E. coli resistance <20%) 1
• Trimethoprim: 200mg twice daily for 5 days (avoid in first trimester of pregnancy) 1
• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days (avoid in last trimester of pregnancy) 1, 3

Treatment for Uncomplicated Pyelonephritis

• Fluoroquinolones: 5-7 days (if local resistance patterns permit) 1
• Trimethoprim-sulfamethoxazole: 14 days (based on antibiotic susceptibility) 1

Special Considerations

Treatment in Men

• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1
• Fluoroquinolones can also be prescribed based on local susceptibility testing 1

Treatment in Pregnancy

• First-line options: Nitrofurantoin (avoid near term >36 weeks), fosfomycin, or cephalexin 4
• Treatment duration: 5-7 days generally recommended 4
• Important: Asymptomatic bacteriuria in pregnancy requires treatment, unlike in non-pregnant women 4

Recurrent UTIs

• Diagnose via urine culture 1
• Consider prophylaxis for frequent recurrences:
  • Nitrofurantoin 50-100mg daily
  • Trimethoprim-sulfamethoxazole 40mg/200mg daily or three times weekly
  • Post-coital prophylaxis may be appropriate 4

Clinical Pearls and Pitfalls

• Urine culture indications: Not routinely needed for uncomplicated cystitis but recommended for:

  • Suspected pyelonephritis
  • Symptoms that don't resolve within 4 weeks after treatment
  • Women with atypical symptoms
  • Pregnant women 1

• Treatment failure: For women whose symptoms don't resolve by end of treatment or recur within 2 weeks:

  • Perform urine culture and susceptibility testing
  • Assume the organism is not susceptible to the original agent
  • Retreat with a 7-day regimen using another agent 1

• Antibiotic resistance concerns: Local resistance patterns should guide empiric therapy choices. Fluoroquinolones should be restricted due to increasing resistance rates and reserved for more severe infections 5, 6

• Symptomatic therapy: For females with mild to moderate symptoms of uncomplicated cystitis, symptomatic therapy (e.g., ibuprofen) may be considered as an alternative to antimicrobial treatment in consultation with individual patients 1

By following these evidence-based guidelines, clinicians can effectively treat UTIs while minimizing antibiotic resistance and optimizing patient outcomes.