Treatment of Cystitis in Men and Women
First-line treatment for uncomplicated cystitis is trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 3 days, but only when local resistance rates are below 20% and the patient has no history of recent TMP-SMX use or international travel. 1
First-Line Treatment Options
For uncomplicated cystitis, the Infectious Diseases Society of America (IDSA) and European Society for Microbiology and Infectious Diseases recommend:
- Trimethoprim-sulfamethoxazole: 160/800 mg (1 double-strength tablet) twice daily for 3 days 1, 2
- Nitrofurantoin monohydrate/macrocrystals: 100 mg twice daily for 5 days 1
- Fosfomycin trometamol: 3 g single dose 1
- Trimethoprim: 100 mg twice daily for 3 days 1
Treatment Selection Algorithm
Check local resistance patterns:
- If E. coli resistance to TMP-SMX is <20%: Use TMP-SMX as first-line
- If resistance is >20% or patient has risk factors for resistance: Use alternative agents
Consider patient-specific factors:
For fluoroquinolones (e.g., ciprofloxacin):
- Reserve as alternative options due to risk of adverse effects
- Ciprofloxacin is FDA-approved for UTIs caused by susceptible strains 3
- Should not be first-line due to concerns about promoting resistance
Special Populations
Men with Cystitis
- Longer treatment duration typically required (7-14 days)
- Consider evaluation for underlying structural abnormalities
- For chronic bacterial prostatitis: Ciprofloxacin is indicated for infections caused by E. coli or Proteus mirabilis 3
Pregnant Women
- Nitrofurantoin 100 mg twice daily for 5-7 days (avoid in third trimester)
- Avoid TMP-SMX in first trimester (risk of neural tube defects) and third trimester (risk of kernicterus) 1
Patients with Diabetes
- Ensure good glycemic control during treatment
- May require longer treatment duration due to higher risk of complications 1
Patients with Renal Impairment
- Avoid nitrofurantoin if GFR <30 ml/min
- For hemodialysis patients: TMP-SMX at half the standard dose (one single-strength tablet daily or one double-strength tablet three times weekly) administered after each dialysis session 1
Treatment Duration
- Uncomplicated cystitis: 3-5 days for most antibiotics (except fosfomycin: single dose) 1
- Complicated cystitis: 5-7 days 1
- Pyelonephritis: 10-14 days 1
Follow-up and Monitoring
- Evaluate clinical response within 48-72 hours of initiating therapy 1
- No routine follow-up urine culture needed in patients who respond to therapy 1
- Follow-up urine culture should be performed 7 days after completing treatment in:
- Pregnant women
- Men
- Patients with complicated infections
- Those with persistent symptoms 1
Prevention of Recurrent Cystitis
For patients with recurrent infections (≥3 episodes/year):
Antibiotic prophylaxis options:
- Nitrofurantoin 50-100 mg daily
- Trimethoprim 100 mg daily
- Post-coital single dose when UTIs are related to sexual activity 1
Non-antibiotic alternatives:
Common Pitfalls to Avoid
- Treating asymptomatic bacteriuria: Increases antibiotic resistance without clinical benefit (except in pregnancy) 1
- Prolonged treatment courses: Increases risk of side effects and resistance without improving outcomes 1
- Not obtaining urine culture before treatment in complicated cases or recurrent infections 1
- Using fluoroquinolones as first-line therapy: Should be reserved for cases where other options cannot be used 1
- Ignoring local resistance patterns: TMP-SMX efficacy is significantly reduced when resistance exceeds 20% 1, 5
Remember that a 5-day course of nitrofurantoin has been shown to be equivalent clinically and microbiologically to a 3-day course of TMP-SMX and should be considered when TMP-SMX cannot be used due to resistance concerns 6.