What is the recommended treatment for a patient with uncomplicated cystitis?

Treatment of Uncomplicated Cystitis

For uncomplicated cystitis in women, the recommended first-line treatment options are nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days, trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (if local resistance is <20%), or fosfomycin trometamol 3 g as a single dose. 1

Understanding Uncomplicated Cystitis

Uncomplicated cystitis refers to a urinary tract infection in patients with a structurally and functionally normal urinary tract. This is different from asymptomatic bacteriuria:

• Uncomplicated cystitis: Presence of bacteria in the urine WITH symptoms (dysuria, frequency, urgency, suprapubic pain)
• Asymptomatic bacteriuria: Presence of bacteria in the urine WITHOUT symptoms

Asymptomatic bacteriuria generally does not require treatment, especially in elderly patients, as treatment increases antibiotic resistance without clinical benefit 1.

First-Line Treatment Options

1. Nitrofurantoin

• Dosage: 100 mg twice daily for 5 days
• Advantages: Minimal resistance patterns, limited collateral damage to gut flora 1
• Efficacy: Superior to fosfomycin with 70% clinical resolution vs 58% for fosfomycin 2
• Contraindications:
  • Suspected early pyelonephritis
  • Renal impairment (GFR <30 ml/min)
  • Infants less than 4 months of age 1

2. Trimethoprim-Sulfamethoxazole (TMP-SMX)

• Dosage: 160/800 mg twice daily for 3 days
• Considerations:
  • Only use if local resistance is <20%
  • Avoid if used for UTI treatment in previous 3 months
  • Avoid if travel outside the country in last 3-6 months 1

3. Fosfomycin Trometamol

• Dosage: 3 g as a single dose 3
• Advantages: Convenient single-dose regimen
• Limitations:
  • Somewhat lower efficacy than other recommended agents
  • Not indicated for pyelonephritis or perinephric abscess 3
  • Clinical resolution rate of 58% compared to 70% for nitrofurantoin 2

Treatment Algorithm

1. Assess patient factors:

   • Renal function (avoid nitrofurantoin if GFR <30 ml/min)
   • Recent antibiotic use (avoid TMP-SMX if used in last 3 months)
   • Travel history (may affect resistance patterns)
   • Pregnancy status

2. Check local resistance patterns:

   • If TMP-SMX resistance <20%: Consider TMP-SMX as first option
   • If TMP-SMX resistance >20%: Use nitrofurantoin or fosfomycin

3. Select treatment based on efficacy and patient factors:

   • First choice: Nitrofurantoin 100 mg BID for 5 days (if normal renal function)
   • Alternative: TMP-SMX 160/800 mg BID for 3 days (if local resistance <20%)
   • Alternative: Fosfomycin 3 g single dose (if compliance is an issue or other options contraindicated)

4. Reserve fluoroquinolones as alternative options due to concerns about promoting resistance 1

Special Considerations

• Renal insufficiency: While traditionally avoided in patients with CrCl <60 ml/min, research suggests nitrofurantoin may still be effective in patients with CrCl 30-60 ml/min 4

• Treatment failure: If persistence or reappearance of bacteriuria occurs after treatment with fosfomycin, select other therapeutic agents 3

• Monitoring: Clinical improvement should be assessed within 48-72 hours 1

Common Pitfalls to Avoid

1. Treating asymptomatic bacteriuria unnecessarily, which increases antibiotic resistance without clinical benefit

2. Using fluoroquinolones as first-line therapy when other effective options are available

3. Not considering local resistance patterns when selecting empiric therapy

4. Using nitrofurantoin in patients with suspected pyelonephritis where it would be ineffective

5. Using TMP-SMX empirically in areas with high resistance rates (>20%)

6. Not adjusting therapy based on culture results when they become available

Remember that the goal of treatment is to achieve clinical resolution while minimizing adverse effects and preventing antimicrobial resistance.