What is the recommended treatment for uncomplicated cystitis in females?

Treatment of Uncomplicated Cystitis in Females

Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is the recommended first-line treatment for uncomplicated cystitis in females due to minimal resistance and limited collateral damage. 1, 2

First-Line Treatment Options

• Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) has clinical cure rates of 88-93% and bacterial cure rates of 81-92%, making it an excellent first choice 1
• Fosfomycin trometamol (3 g single dose) is an appropriate alternative first-line option with minimal resistance, though it may have slightly inferior efficacy compared to standard regimens 1, 3
• Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) is appropriate first-line therapy only when local resistance rates of uropathogens are known to be <20% or the infecting strain is confirmed susceptible 1, 2

Treatment Algorithm

1. First choice: Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) 1, 2
2. Second choice: Fosfomycin trometamol (3 g single dose) 2, 3
3. Third choice: Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), but only if local resistance is <20% 1, 2
4. Alternative options (when first-line agents cannot be used):
   • Fluoroquinolones (3-day regimens) 1, 4
   • β-Lactams (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) for 3-7 days 1, 5

Efficacy Considerations

• Nitrofurantoin has shown similar clinical cure rates to ciprofloxacin (93% vs 95%) and trimethoprim-sulfamethoxazole (93% vs 95%) 1, 2
• Fosfomycin demonstrates clinical cure rates of approximately 90%, but microbiological cure rates may be lower (78%) compared to nitrofurantoin (86%) 1, 2
• Trimethoprim-sulfamethoxazole shows significantly reduced efficacy against resistant organisms (clinical cure rates of 41-54% for resistant strains vs 84-88% for susceptible strains) 1, 2

Special Considerations

• For patients with sulfa allergies, nitrofurantoin and fosfomycin are preferred options 2
• For patients with both penicillin and sulfa allergies, nitrofurantoin and fosfomycin remain the preferred options 2
• Fluoroquinolones should be reserved as alternative agents despite their high efficacy due to their propensity for promoting resistance to these important agents needed for more serious infections 1, 2, 4

Common Pitfalls to Avoid

• Using fluoroquinolones as first-line therapy despite their high efficacy, as this promotes resistance 1, 6
• Prescribing trimethoprim-sulfamethoxazole empirically in areas with high resistance rates (>20%) 1, 7
• Using amoxicillin or ampicillin for empirical treatment due to poor efficacy and high prevalence of antimicrobial resistance worldwide 1, 8
• Prescribing longer treatment durations than necessary - studies show significant overprescribing of antibiotics beyond recommended durations 6
• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 2

Follow-up Recommendations

• For women whose symptoms do not resolve by the end of treatment or recur within 2 weeks, obtain a urine culture and antimicrobial susceptibility testing 2, 5
• If persistence or reappearance of bacteriuria occurs after treatment with fosfomycin, select other therapeutic agents 3
• Consider retreatment with a 7-day regimen using another agent if symptoms persist or recur 2