What are the recommended drugs for treating uncomplicated cystitis?

Recommended Drugs for Uncomplicated Cystitis

Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is the first-line treatment for uncomplicated cystitis due to its high efficacy and minimal resistance. 1

First-Line Treatment Options

• Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) demonstrates clinical cure rates of 88-93% and bacterial cure rates of 81-92% 1, 2
• Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) is appropriate first-line therapy only when local resistance rates are known to be <20% or the infecting strain is confirmed susceptible 1, 2
• Fosfomycin trometamol (3 g single dose) is an appropriate first-line option with clinical cure rates around 90%, though microbiological cure rates may be slightly lower (78%) compared to nitrofurantoin (86%) 1, 3
• Pivmecillinam (400 mg twice daily for 3-7 days) is recommended in regions where available (primarily European countries) 1

Second-Line Treatment Options

• Fluoroquinolones (ciprofloxacin, levofloxacin, norfloxacin) are highly effective in 3-day regimens but should be reserved as alternative agents due to their propensity for promoting resistance and collateral damage 1, 4
• β-Lactam agents (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) in 3-7 day regimens should be used only when first-line agents cannot be used, as they generally have inferior efficacy and more adverse effects 2, 1
• Other β-lactams like cephalexin are less studied but may be appropriate in certain settings 2

Treatments to Avoid

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

Treatment Algorithm for Uncomplicated Cystitis

1. First choice: Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) 1, 5
2. Second choice: Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) if local resistance <20% 1, 6
3. Third choice: Fosfomycin trometamol (3 g single dose) 1, 3
4. Fourth choice: Fluoroquinolones (3-day regimen) - only when first-line agents cannot be used 1, 7
5. Fifth choice: β-lactams (3-7 day regimen) - only when other options are unavailable 2, 1

Special Considerations

• For patients with sulfa allergies: Use nitrofurantoin, fosfomycin, or fluoroquinolones 8
• For patients with penicillin allergies: All first-line options remain appropriate 8
• For patients with both sulfa and penicillin allergies: Nitrofurantoin and fosfomycin are preferred options 8

Efficacy Comparisons

• Nitrofurantoin has shown similar clinical cure rates to ciprofloxacin (93% vs 95%) and trimethoprim-sulfamethoxazole (93% vs 95%) 2, 1
• Trimethoprim-sulfamethoxazole shows significantly reduced efficacy against resistant organisms (clinical cure rates of 41-54% for resistant strains vs 84-88% for susceptible strains) 2, 1
• Despite guidelines recommending first-line agents, studies show low adherence with fluoroquinolones still being commonly prescribed (51.6% of prescriptions in one study) 9

Common Pitfalls to Avoid

• Using fluoroquinolones as first-line therapy despite their high efficacy, as this promotes resistance to these important agents needed for more serious infections 1, 4
• Prescribing trimethoprim-sulfamethoxazole empirically in regions with high resistance rates (>20%) 1, 7
• Using amoxicillin or ampicillin empirically due to high resistance rates 2, 1
• Prescribing longer treatment durations than recommended (a common issue seen in 71-82% of prescriptions) 9

Follow-up Recommendations

• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 6
• 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 5, 6