Initial Treatment for Cystitis
For uncomplicated cystitis in women, first-line treatment options include nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days, or fosfomycin as a single dose, with the choice guided by local resistance patterns. 1
First-Line Treatment Options for Uncomplicated Cystitis in Women
- Nitrofurantoin - 100 mg twice daily for 5 days (macrocrystals/monohydrate) or 50-100 mg four times daily for 5 days (macrocrystals) 1
- Fosfomycin trometamol - 3 g single dose; appropriate due to minimal resistance and low collateral damage, though may have slightly inferior efficacy compared to standard short-course regimens 1
- Trimethoprim-sulfamethoxazole (TMP-SMX) - 160/800 mg (double-strength tablet) twice daily for 3 days; appropriate if local resistance rates of uropathogens do not exceed 20% or if the infecting strain is known to be susceptible 1, 2
- Pivmecillinam - 400 mg three times daily for 3-5 days (availability limited to some European countries) 1
Treatment Selection Considerations
- Local resistance patterns are crucial in selecting empiric therapy. TMP-SMX should not be used if local E. coli resistance exceeds 20% 1
- Fluoroquinolones (ofloxacin, ciprofloxacin, levofloxacin) are highly efficacious in 3-day regimens but should be reserved for important uses other than uncomplicated cystitis due to their propensity for promoting antimicrobial resistance 1
- Beta-lactams (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) should be used only when other recommended agents cannot be used, as they generally have inferior efficacy and more adverse effects 1
- Amoxicillin or ampicillin should not be used for empirical treatment due to poor efficacy and high prevalence of resistance 1
Treatment in Men
- TMP-SMX - 160/800 mg twice daily for 7 days is the recommended treatment for men with cystitis 1
- Fluoroquinolones can also be prescribed based on local susceptibility testing 1
Special Considerations
Urine culture is generally not needed for typical uncomplicated cystitis but is recommended in:
- Suspected pyelonephritis
- Symptoms that don't resolve or recur within 4 weeks after treatment
- Women with atypical symptoms
- Pregnant women 1
Post-treatment follow-up: Routine urinalysis or urine cultures are not indicated for asymptomatic patients 1
Treatment failure: For women whose symptoms don't resolve by the end of treatment or recur within 2 weeks, perform urine culture and susceptibility testing. Retreatment with a 7-day regimen using a different agent is recommended 1
Symptomatic therapy: For females with mild to moderate symptoms, symptomatic therapy (e.g., ibuprofen) may be considered as an alternative to antimicrobial treatment in some cases 1
Common Pitfalls to Avoid
- Using fluoroquinolones as first-line therapy despite their high efficacy due to concerns about promoting resistance 1
- Prescribing TMP-SMX empirically in areas with high resistance rates (>20%) 1
- Treating asymptomatic bacteriuria in most patient populations (exceptions include pregnant women and patients before urological procedures breaching the mucosa) 1
- Inadequate treatment duration - shorter regimens than recommended may lead to treatment failure and recurrence 3
- Failure to consider local resistance patterns when selecting empiric therapy 1