Treatment for Cystitis Symptoms
Nitrofurantoin 100 mg twice daily for 5 days is the optimal first-line treatment for acute uncomplicated cystitis, offering excellent efficacy with minimal resistance and collateral damage. 1
First-Line Antibiotic Options
The choice of empirical therapy depends on local resistance patterns and drug availability:
Preferred First-Line Agents
Nitrofurantoin: 100 mg twice daily for 5 days is the top choice due to minimal resistance, low collateral damage (disruption of normal flora leading to secondary infections), and efficacy comparable to 3-day trimethoprim-sulfamethoxazole regimens 1
Trimethoprim-sulfamethoxazole (TMP-SMX): 160/800 mg (one double-strength tablet) twice daily for 3 days is appropriate only if local E. coli resistance rates are below 20% or if the organism is known to be susceptible 1, 2
Fosfomycin trometamol: 3 g single oral dose is appropriate due to minimal resistance and collateral damage, though it has slightly inferior efficacy compared to standard short-course regimens based on FDA data 1
Alternative First-Line Agents (Region-Dependent)
- Pivmecillinam: 400 mg twice daily for 3-7 days is appropriate in European countries where available, but may have inferior efficacy compared to other options 1
Second-Line Antibiotic Options
Reserve these agents when first-line options cannot be used:
Fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin): Highly efficacious in 3-day regimens but should be reserved for more serious infections due to significant collateral damage and the need to preserve their effectiveness 1
Beta-lactams (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil): Use 3-7 day regimens only when other agents cannot be used, as they have inferior efficacy and more adverse effects 1
- Cephalexin is less well studied but may be appropriate in certain settings 1
Treatment Duration
- Treat acute cystitis episodes with as short a duration as reasonable, generally no longer than 7 days 1
- Most first-line agents are effective in 3-5 day courses 1, 3
Important Considerations Before Treatment
When to Obtain Urine Culture
- Obtain urine culture and sensitivity testing before initiating treatment in patients with recurrent UTIs to document infection and guide therapy 1
- Culture is not necessary for straightforward first episodes of acute uncomplicated cystitis in healthy women 4
- Always obtain culture if symptoms persist or recur within 2-4 weeks after treatment, or if atypical symptoms are present 4
Patient-Initiated Treatment
- Consider offering self-start treatment to select patients with recurrent UTIs while awaiting culture results, allowing them to initiate antibiotics at symptom onset 1
- This strategy minimizes antibiotic exposure compared to long-term prophylaxis 5
Critical Pitfalls to Avoid
- Never use amoxicillin or ampicillin empirically due to poor efficacy and very high worldwide resistance rates 1
- Do not treat asymptomatic bacteriuria detected on routine testing—this contributes to antibiotic overuse and resistance 1, 6
- Do not routinely perform post-treatment urine cultures in asymptomatic patients; focus on clinical response instead 6
Special Consideration: Withholding Antibiotics
Recent evidence suggests that withholding antibiotics in emergency department patients with provisional cystitis diagnosis is not recommended 1. While 30-50% of patients may achieve symptom resolution with NSAIDs or placebo by days 3-4, studies consistently show:
- Increased symptom burden (severity and duration) without immediate antibiotics 1
- 5-6 times higher risk of progression to pyelonephritis (3.6% vs 0.4%) when antibiotics are withheld, with an odds ratio of 5.6 1
- This data applies specifically to healthy, non-pregnant women with uncomplicated cystitis in primary care settings 1