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). 1

Diagnosis and Classification

• Uncomplicated cystitis is defined as acute, sporadic, or recurrent cystitis in non-pregnant women without relevant anatomic or functional urinary tract abnormalities and no comorbidities 1
• Diagnosis is primarily clinical, based on lower urinary tract symptoms including dysuria, frequency, and urgency, with absence of vaginal discharge 1, 2
• In patients with typical symptoms, urine analysis provides minimal increase in diagnostic accuracy, but dipstick testing can be helpful when diagnosis is unclear 1
• Urine culture is recommended in specific situations: suspected pyelonephritis, symptoms that don't resolve within 4 weeks after treatment, women with atypical symptoms, and pregnant women 1, 2

Treatment Algorithm for Cystitis

First-line Treatment Options for Women with Uncomplicated Cystitis:

• Fosfomycin trometamol: 3g single dose 1
• Nitrofurantoin macrocrystals: 50-100mg four times daily for 5 days 1
• Nitrofurantoin monohydrate/macrocrystals: 100mg twice daily for 5 days 1
• Pivmecillinam: 400mg three times daily for 3-5 days 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 (not in first trimester of pregnancy) 1
• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days (not in last trimester of pregnancy, and only in regions where E. coli resistance <20%) 1, 3

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, efficacy in clinical studies, tolerability, adverse effects, ecological impact, and cost/availability 1, 4
• Fluoroquinolones are highly efficacious but should be reserved for more serious infections due to their propensity for collateral damage (ecological adverse effects) 1
• Beta-lactams generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials 1
• Amoxicillin or ampicillin should not be used for empirical treatment due to poor efficacy and high prevalence of resistance 1

Follow-up and Treatment Failure

• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1
• For women whose symptoms don't resolve by the end of treatment or recur within 2 weeks, urine culture and antimicrobial susceptibility testing should be performed 1
• For treatment failures, assume the infecting organism is not susceptible to the agent originally used and retreat with a 7-day regimen using another agent 1

Recurrent UTIs

• Recurrent UTIs are defined as at least three UTIs per year or two UTIs in the last 6 months 1
• Diagnosis requires urine culture confirmation 1
• For patients with recurrent UTIs, self-initiated treatment (patient-initiated therapy) may be offered when symptoms develop, while awaiting urine culture results 1, 5
• Treatment of each episode as soon as symptoms appear is the strategy that uses the fewest antibiotics 5

Common Pitfalls to Avoid

• Don't treat asymptomatic bacteriuria except in pregnant women or before urological procedures breaching the mucosa 1
• Don't use fluoroquinolones as first-line therapy for uncomplicated cystitis due to risk of collateral damage and need to preserve efficacy for more serious infections 1, 4
• Don't perform extensive workup (cystoscopy, abdominal ultrasound) in women younger than 40 years with recurrent UTI and no risk factors 1
• Don't use trimethoprim-sulfamethoxazole empirically in regions where E. coli resistance exceeds 20% 1, 4
• Don't forget to consider local antibiotic resistance patterns when selecting empiric therapy 4