What are the recommended drugs for treating chronic cystitis?

Drug Treatment for Chronic Cystitis

For chronic cystitis, nitrofurantoin (100 mg twice daily for 5-7 days) is recommended as first-line therapy, with trimethoprim-sulfamethoxazole and fosfomycin as alternatives when local resistance patterns are favorable. 1

First-Line Treatment Options

Nitrofurantoin

• Dosage: 100 mg twice daily for 5-7 days
• Advantages: Effective against most common uropathogens
• Contraindications:
  • Avoid in renal impairment (GFR <30 ml/min)
  • Avoid in third trimester of pregnancy
  • Not recommended for infants under 4 months due to risk of hemolytic anemia 1

Trimethoprim-Sulfamethoxazole (TMP-SMX)

• Dosage: 1 double-strength tablet (800 mg/160 mg) every 12 hours for 10-14 days 2
• Only recommended when local resistance rates are <20% (clinical cure rates drop significantly with resistant organisms) 1
• Adjust dosage in renal impairment:
  • CrCl 30-50 mL/min: Standard dose
  • CrCl 15-30 mL/min: Half the usual regimen
  • CrCl <15 mL/min: Not recommended 2

Fosfomycin

• Dosage: 3 g single dose
• Good option for uncomplicated cystitis 1
• Particularly useful when antibiotic resistance is a concern 3

Second-Line Treatment Options

Fluoroquinolones (e.g., Ciprofloxacin)

• Dosage: 500 mg twice daily for 7-14 days 4
• Particularly effective for complicated UTIs when local fluoroquinolone resistance is <10% 1
• Should be reserved as second-line agents due to resistance concerns and adverse effects 3
• Avoid as first-line agents in elderly patients due to increased risk of adverse effects 1

Cephalosporins

• Cefalexin 500 mg four times daily for 7-14 days (14 days for men when prostatitis cannot be excluded) 1
• Recommended for complicated UTIs or when other options aren't suitable

Special Considerations

Duration of Treatment

• Uncomplicated cystitis: 3-7 days
• Complicated cystitis: 7-14 days 1

Patient-Specific Factors

1. Pregnant Women:

   • Nitrofurantoin 100 mg twice daily for 5-7 days (if normal renal function)
   • Avoid nitrofurantoin in third trimester
   • Cephalosporins (e.g., cefuroxime) are safe alternatives 3

2. Patients with Renal Impairment:

   • Avoid nitrofurantoin if GFR <30 ml/min
   • Adjust TMP-SMX dosage according to creatinine clearance 2

3. 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

4. Elderly Patients:

   • Avoid fluoroquinolones as first-line therapy
   • Consider increased fluid intake (additional 1.5L daily) to help prevent recurrence 1

Management of Recurrent Cystitis

For patients experiencing recurrent cystitis (≥3 episodes/year or ≥2 episodes in 6 months) 3:

1. Self-initiated therapy:

   • Short course of antibiotics at first sign of symptoms
   • This approach minimizes overall antibiotic exposure 5

2. Prophylactic options:

   • Nitrofurantoin 50-100 mg daily
   • Trimethoprim 100 mg daily
   • Post-coital single dose when UTIs are related to sexual activity 1
   • Non-antibiotic prophylaxis (e.g., oral immunostimulant OM-89) may be considered to reduce antibiotic consumption 3

Important Caveats

• Local antimicrobial susceptibility patterns should guide empiric therapy choices 1
• Evaluate clinical response within 48-72 hours of initiating therapy 1
• Follow-up urine culture should be performed 7 days after completing treatment 1
• Interstitial cystitis, though presenting with similar symptoms, is not bacterial in nature and does not respond to antibiotics 6
• Asymptomatic bacteriuria should not be treated in elderly patients as this increases antibiotic resistance without clinical benefit 1