First-Line Treatment for Uncomplicated Cystitis
For uncomplicated cystitis in women, nitrofurantoin (100 mg twice daily for 5 days) is the preferred first-line treatment, offering excellent efficacy with minimal resistance and limited collateral damage to normal flora. 1, 2
Primary Treatment Options
The 2024 European Association of Urology guidelines establish three first-line antimicrobial options for women with uncomplicated cystitis: 1
Nitrofurantoin (Preferred)
- Nitrofurantoin monohydrate/macrocrystals: 100 mg twice daily for 5 days 1, 2
- Alternative dosing: 50-100 mg four times daily for 5 days 1
- Clinical cure rates of 90% at 5-9 days and 84% at 30 days 3
- Maintains excellent activity against E. coli despite 60+ years of use 4
- Contraindicated when eGFR <30 mL/min 2
- Avoid in the last trimester of pregnancy 4
Fosfomycin Trometamol
- Single 3-gram dose, taken once 1, 5
- FDA-approved specifically for acute cystitis in women 5
- Must be mixed with water before ingesting; never take in dry form 5
- May have slightly inferior efficacy compared to nitrofurantoin but offers unmatched convenience 2
- Excellent option for patients with sulfa or penicillin allergies 2
Pivmecillinam
- 400 mg three times daily for 3-5 days 1, 2
- Recommended where available (limited availability in some regions) 2
Alternative Treatment Options
Trimethoprim-Sulfamethoxazole
- 160/800 mg twice daily for 3 days 1, 6
- Only use when local E. coli resistance rates are documented to be <20% 1, 2
- Clinical cure drops dramatically from 84% to 41% when treating resistant organisms 1, 3
- Avoid in first trimester of pregnancy 1
- Historically effective but increasingly limited by resistance 4, 3
Cephalosporins
- Cefadroxil 500 mg twice daily for 3 days 1, 2
- Only if local E. coli resistance is <20% 1
- Not recommended for initial treatment due to resistance concerns 6
Fluoroquinolones
- Reserve for more serious infections; avoid as first-line for simple cystitis 2
- Promotes resistance and should be preserved for complicated cases 2
Diagnostic Approach
Clinical Diagnosis
- Diagnosis can be made based on symptoms alone: dysuria, frequency, urgency, and absence of vaginal discharge 1, 2
- Urine dipstick or culture adds minimal diagnostic accuracy in typical presentations 1
When to Order Urine Culture
Obtain urine culture in these specific situations: 1, 2
- Suspected acute pyelonephritis
- Symptoms not resolving or recurring within 4 weeks after treatment
- Atypical symptoms
- Pregnancy
- Treatment failure or recurrence within 2 weeks
Treatment in Men
Men require longer treatment duration (7 days) due to different anatomical considerations: 1, 2
- Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days 1, 2
- Fluoroquinolones based on local susceptibility testing 1, 2
Non-Antimicrobial Option
For mild to moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to antibiotics after patient consultation 1
Treatment Failure Management
If symptoms persist at end of treatment or recur within 2 weeks: 1, 2
- Obtain urine culture and antimicrobial susceptibility testing 1, 2
- Assume the organism is not susceptible to the initially used agent 1
- Retreat with a 7-day regimen using a different antimicrobial 1, 2
Critical Contraindications and Cautions
- Nitrofurantoin: avoid when eGFR <30 mL/min 2
- Trimethoprim: not in first trimester of pregnancy 1
- Trimethoprim-sulfamethoxazole: not in last trimester of pregnancy 1
- Fosfomycin: appropriate for sulfa and penicillin allergies 2
Post-Treatment Follow-Up
Routine post-treatment urinalysis or urine cultures are NOT indicated for asymptomatic patients 1