What is the recommended treatment for a patient with cystitis?

Treatment of Cystitis

For uncomplicated cystitis, first-line treatment options include fosfomycin trometamol (3g single dose), nitrofurantoin (100mg twice daily for 5 days), or pivmecillinam (400mg three times daily for 3-5 days), with the choice guided by local resistance patterns and patient factors. 1

Diagnosis and Classification

• Uncomplicated cystitis is defined as acute, sporadic, or recurrent cystitis in non-pregnant women without anatomic or functional urinary tract abnormalities or comorbidities 1
• Diagnosis can be made with high probability based on lower urinary tract symptoms (dysuria, frequency, urgency) and absence of vaginal discharge 1
• In patients with typical symptoms, urine analysis provides minimal increase in diagnostic accuracy, but dipstick testing can help when diagnosis is unclear 1
• Urine culture is recommended for:
  • Suspected pyelonephritis
  • Symptoms that don't resolve or recur within 4 weeks after treatment
  • Women with atypical symptoms
  • Pregnant women 1

Treatment Recommendations for Uncomplicated Cystitis

First-line Treatment Options for Women:

• Fosfomycin trometamol: 3g single dose 1

  • Advantages: Minimal resistance, low collateral damage, single-dose convenience
  • Limitation: May have slightly inferior efficacy compared to other regimens

• Nitrofurantoin: Multiple formulation options 1

  • Macrocrystals: 50-100mg four times daily for 5 days
  • Monohydrate/macrocrystals: 100mg twice daily for 5 days
  • Macrocrystals prolonged release: 100mg twice daily for 5 days

• Pivmecillinam: 400mg three times daily for 3-5 days (availability limited to some European countries) 1

Alternative Options (when first-line agents cannot be used):

• Cephalosporins (e.g., cefadroxil): 500mg twice daily for 3 days (if local E. coli resistance <20%) 1

• Trimethoprim: 200mg twice daily for 5 days (avoid in first trimester of pregnancy) 1

• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days (avoid in last trimester of pregnancy, use only if local resistance <20%) 1, 2

• Fluoroquinolones: Highly effective but should be reserved for more serious infections due to concerns about collateral damage and resistance 1

Treatment for Men:

• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 7 days 1
• Fluoroquinolones can be prescribed according to local susceptibility testing 1

Special Considerations

• For women with mild to moderate symptoms, symptomatic therapy (e.g., ibuprofen) may be considered as an alternative to antimicrobial treatment in consultation with individual patients 1

• The choice of antimicrobial should be guided by:

  • Local resistance patterns of uropathogens
  • Efficacy demonstrated in clinical studies
  • Tolerability and adverse reactions
  • Ecological effects (impact on normal flora)
  • Cost and availability 1

• For symptoms that don't resolve by the end of treatment or recur within 2 weeks:

  • Perform urine culture and antimicrobial susceptibility testing
  • Assume the infecting organism is not susceptible to the original agent
  • Consider retreatment with a 7-day regimen using a different agent 1

• Routine post-treatment urinalysis or cultures are not indicated for asymptomatic patients 1

Management of Recurrent UTIs

• Defined as ≥3 UTIs per year or ≥2 UTIs in the last 6 months 1
• Diagnose via urine culture (strong recommendation) 1
• Extensive workup (cystoscopy, abdominal ultrasound) not recommended for women <40 years without risk factors 1
• Preventive measures include:
  • Increased fluid intake in premenopausal women 1
  • Vaginal estrogen replacement in postmenopausal women 1
  • Immunoactive prophylaxis 1
  • Consider probiotics for vaginal flora regeneration 1
  • Cranberry products may help reduce recurrence, though evidence is mixed 1

Common Pitfalls and Caveats

• Using fluoroquinolones as first-line therapy when other options are available (increases risk of resistance) 1
• Using amoxicillin or ampicillin empirically (high resistance rates worldwide) 1
• Treating asymptomatic bacteriuria outside of specific indications (pregnancy, before urological procedures breaching mucosa) 1
• Failing to obtain cultures in patients with recurrent or persistent symptoms 1
• Not adjusting therapy based on local resistance patterns, particularly for trimethoprim-sulfamethoxazole 1
• Prescribing longer courses of antibiotics than necessary (3-5 days is typically sufficient for uncomplicated cystitis) 1, 3