What is the first-line treatment for cystitis vs lower urinary tract infection (UTI)?

Cystitis and Lower UTI: Terminology and First-Line Treatment

Key Distinction

Cystitis and uncomplicated lower urinary tract infection (UTI) are essentially the same clinical entity—both refer to bladder infection in otherwise healthy individuals without anatomical or functional urinary tract abnormalities. 1, 2 The terms are used interchangeably in clinical practice, with "cystitis" being the more specific medical term for bladder inflammation/infection, while "lower UTI" is the broader descriptor distinguishing it from upper tract infections (pyelonephritis). 1

First-Line Treatment for Women with Uncomplicated Cystitis/Lower UTI

The 2024 European Association of Urology guidelines establish three equally appropriate first-line antibiotic options: 1

Primary First-Line Agents

• Fosfomycin trometamol 3 g single dose - Most convenient option with single-dose administration 1, 3

  • FDA-approved specifically for acute cystitis in women caused by E. coli and Enterococcus faecalis 3
  • Particularly useful when compliance is a concern 1

• Nitrofurantoin macrocrystals or monohydrate 100 mg twice daily for 5 days 1

  • Minimal resistance patterns and low collateral damage to normal flora 1, 4
  • Multiple formulations available (macrocrystals, monohydrate, prolonged-release) 1

• Pivmecillinam 400 mg three times daily for 3-5 days 1

  • Effective first-line option where available 1

Alternative Second-Line Options

When first-line agents are unavailable or contraindicated, consider: 1

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days - Only if local E. coli resistance is <20% 1, 5, 4

  • Avoid in first trimester of pregnancy due to teratogenic concerns 1
  • Increasing resistance rates limit empiric use in many communities 6

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

Critical Pitfalls to Avoid

Fluoroquinolones should NOT be used as first-line therapy for uncomplicated cystitis: 1

• The FDA issued warnings in 2016 about disabling and serious adverse effects creating an unfavorable risk-benefit ratio 1
• Reserve for complicated infections or pyelonephritis only 1, 4
• Significant collateral damage to protective microbiota 1

Beta-lactam antibiotics (amoxicillin, amoxicillin-clavulanate) are inferior first-line choices: 1, 4

• Lower efficacy compared to other first-line agents 4
• Promote more rapid UTI recurrence due to disruption of protective vaginal/periurethral flora 1

Treatment Duration Considerations

Short-course therapy is standard for uncomplicated cystitis in women: 1

• 1 day for fosfomycin 1
• 3-5 days for pivmecillinam 1
• 5 days for nitrofurantoin 1
• 3 days for trimethoprim-sulfamethoxazole (when appropriate) 1

Longer courses (7 days) are NOT more effective and increase resistance risk and adverse effects. 1

Treatment in Men

Men with lower UTI require longer treatment duration (7 days minimum): 1

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is recommended 1
• Fluoroquinolones may be used based on local susceptibility patterns 1
• Limited evidence supports this approach, but expert consensus favors extended therapy due to potential prostatic involvement 4

Diagnostic Approach

Urine culture is NOT routinely needed for straightforward uncomplicated cystitis in non-pregnant women: 1, 4

• Clinical diagnosis based on dysuria and frequency is sufficient 4, 2
• Urinalysis (dipstick or microscopy) can support diagnosis but is not mandatory 2

Urine culture IS indicated in specific situations: 1

• Suspected pyelonephritis 1
• Pregnancy 1, 7
• Symptoms not resolving or recurring within 4 weeks after treatment 1
• Atypical symptoms 1

Alternative to Antibiotics

For women with mild-to-moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to immediate antibiotics after shared decision-making. 1 However, immediate antimicrobial therapy remains the standard recommendation for most cases to prevent progression and ensure rapid symptom resolution. 4