What is the recommended treatment and duration for acute cystitis?

Treatment and Duration for Acute Uncomplicated Cystitis

Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is the recommended first-line treatment for acute uncomplicated cystitis due to its minimal resistance patterns, limited collateral damage, and efficacy comparable to other agents. 1, 2

First-Line Treatment Options

• Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is highly effective with clinical cure rates of 88-93% and bacterial cure rates of 81-92% 2, 3
• Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) is appropriate first-line therapy only when local resistance rates are <20% or the infecting strain is confirmed susceptible 1, 2
• Fosfomycin trometamol (3 g single dose) is appropriate where available, though it may have slightly inferior efficacy compared to standard short-course regimens 1
• Pivmecillinam (400 mg twice daily for 3-7 days) is recommended in regions where available (primarily European countries) 1, 2

Alternative Treatment Options

• Fluoroquinolones (ofloxacin, ciprofloxacin, levofloxacin) are highly effective in 3-day regimens but should be reserved as alternative agents due to concerns about collateral damage and increasing resistance 1, 2
• β-Lactam agents (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) in 3-7 day regimens should only be used when first-line agents cannot be used due to inferior efficacy and more adverse effects 1
• A randomized trial showed cefpodoxime was inferior to ciprofloxacin for acute uncomplicated cystitis, with clinical cure rates of 82% vs 93%, respectively 4

Treatments to Avoid

• Amoxicillin or ampicillin should not be used for empirical treatment due to poor efficacy and high prevalence of antimicrobial resistance worldwide 1, 2

Treatment Duration

• Nitrofurantoin requires 5 days of treatment 1, 3
• Trimethoprim-sulfamethoxazole is effective with 3 days of treatment 1, 5
• Fosfomycin is administered as a single 3g dose 1, 2
• Fluoroquinolones are effective in 3-day regimens 1, 2
• β-Lactams require 3-7 days of treatment 1

Special Considerations

• For trimethoprim-sulfamethoxazole, clinical cure rates drop significantly with resistant organisms (41-54% for resistant strains vs 84-88% for susceptible strains) 1, 2
• A comparative study showed a 5-day course of nitrofurantoin is equivalent clinically and microbiologically to a 3-day course of trimethoprim-sulfamethoxazole 3
• Urine cultures are not routinely recommended for uncomplicated cystitis but should be obtained in women with suspected pyelonephritis, symptoms that do not resolve or recur within 2-4 weeks after treatment, or atypical symptoms 6

Treatment Algorithm

1. First assess if patient has uncomplicated cystitis (frequency and dysuria in an immunocompetent woman without comorbidities or urologic abnormalities) 6
2. If local resistance to trimethoprim-sulfamethoxazole is <20%:
   • Use either nitrofurantoin 100 mg BID for 5 days OR trimethoprim-sulfamethoxazole 160/800 mg BID for 3 days 1, 2
3. If local resistance to trimethoprim-sulfamethoxazole is >20% or unknown:
   • Use nitrofurantoin 100 mg BID for 5 days as first choice 1, 2
4. If nitrofurantoin cannot be used:
   • Use fosfomycin 3 g single dose (where available) 1
5. Reserve fluoroquinolones for situations where first-line agents cannot be used 1, 2
6. Use β-lactams only when no other options are available 1