What is the appropriate treatment for a patient with recurrent acute cystitis caused by β-hemolytic Streptococcus, Group B (GBS), with symptoms of dysuria and urinalysis (UA) showing pyuria?

Treatment of Recurrent Acute Cystitis Caused by Group B Streptococcus (GBS)

For recurrent acute cystitis caused by Group B Streptococcus with confirmed susceptibility, nitrofurantoin 100 mg twice daily for 5 days is the recommended first-line treatment. 1

First-Line Treatment Options

• Nitrofurantoin (100 mg twice daily for 5 days) is the preferred first-line agent for uncomplicated cystitis, including GBS infections, due to minimal resistance and limited collateral damage to normal flora 1
• Fosfomycin trometamol (3 g single dose) is an appropriate alternative with minimal resistance, though it may have slightly inferior efficacy compared to standard regimens 1
• Pivmecillinam (400 mg three times daily for 3-5 days) can be considered where available 1

Alternative Treatment Options

• Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) are appropriate when first-line agents cannot be used 1
• Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) can be used if the organism is known to be susceptible 1
• Fluoroquinolones should be reserved for more severe infections due to their propensity for collateral damage and increasing resistance 1

Special Considerations for GBS

• Group B Streptococcus is typically nitrite-negative on urinalysis, which is consistent with the clinical presentation 2, 3
• GBS urinary tract infections often occur in patients with underlying urinary tract abnormalities, so evaluation for anatomical issues should be considered if infections are recurrent 3
• For GBS infections, ensure complete eradication with appropriate treatment duration to prevent recurrence 4

Management of Recurrent UTIs

• Diagnose recurrent UTI via urine culture to confirm the causative organism and its susceptibility pattern 1
• For patients with good compliance, self-administered short-term antimicrobial therapy can be considered for prompt treatment of recurrent episodes 1
• When non-antimicrobial interventions have failed, continuous or postcoital antimicrobial prophylaxis may be necessary 1

Non-Antimicrobial Prevention Strategies

• Increase fluid intake to reduce the risk of recurrent UTI 1
• Consider methenamine hippurate to reduce recurrent UTI episodes in women without abnormalities of the urinary tract 1
• For postmenopausal women, vaginal estrogen replacement should be used to prevent recurrent UTI 1
• Immunoactive prophylaxis can be considered to reduce recurrent UTI episodes 1

Follow-up Recommendations

• If symptoms do not resolve by the end of treatment or recur within 2 weeks, perform a urine culture and antimicrobial susceptibility testing 1
• For treatment failure, assume the organism is not susceptible to the original agent and retreat with a 7-day regimen using a different antimicrobial 1
• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1

Pitfalls and Caveats

• Beta-lactams generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials and should be used with caution 1
• Amoxicillin or ampicillin should not be used for empirical treatment due to relatively poor efficacy and high prevalence of resistance 1
• Despite GBS being universally susceptible to penicillin in vitro, penicillin treatment failures can occur in practice, particularly in patients recently treated with the drug 4
• Nitrofurantoin should not be used in patients with significant renal impairment or for suspected upper urinary tract infection 1