What is the initial treatment for acute cystitis with hematuria?

Treatment of Acute Cystitis with Hematuria

Acute cystitis with hematuria should be treated identically to acute uncomplicated cystitis without hematuria, using first-line antibiotics such as nitrofurantoin (100 mg twice daily for 5 days) or trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days if local resistance is <20%). 1, 2

Initial Management Approach

The presence of hematuria in acute cystitis does not change the antibiotic selection or treatment duration, as hematuria is a common presenting symptom of bacterial cystitis and resolves with appropriate antimicrobial therapy. 3, 4

First-Line Treatment Options

Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is the preferred first-line agent due to:

• Minimal resistance patterns and limited collateral damage 1, 2
• Clinical cure rates of 88-93% and bacterial cure rates of 81-92% 2
• Comparable efficacy to trimethoprim-sulfamethoxazole 1, 2

Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) is appropriate when:

• Local resistance rates are documented to be <20% 1, 2, 5
• The patient has not used this agent for UTI in the previous 3 months 1
• Clinical cure rates of 84-88% for susceptible strains 2

Alternative Treatment Options

Fosfomycin trometamol (3 g single dose) can be used when first-line agents are contraindicated:

• Clinical cure rates of approximately 90% 2
• Slightly lower microbiological cure rates (78%) compared to nitrofurantoin (86%) 2
• Should be avoided if early pyelonephritis is suspected 1

Fluoroquinolones (ciprofloxacin, levofloxacin for 3 days) should be reserved as alternative agents:

• Highly effective but should not be used as first-line therapy 1, 2
• Reserved for more serious infections due to concerns about promoting resistance 1, 2

Critical Assessment for Pyelonephritis

Before initiating treatment, ensure the patient does NOT have signs of upper tract infection:

• Absence of fever 1
• Absence of flank pain or costovertebral angle tenderness 1
• Absence of systemic symptoms (nausea, vomiting) 1

If any of these features are present, treat as pyelonephritis with fluoroquinolones or other appropriate agents for 7-14 days and obtain urine culture. 1

Agents to Avoid

Amoxicillin or ampicillin should never be used empirically due to:

• Poor efficacy and high prevalence of antimicrobial resistance worldwide 1, 2

β-Lactam agents (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) are inferior choices:

• Generally have lower efficacy and more adverse effects compared to first-line agents 1, 2
• Should only be used when first-line agents cannot be used 2

Common Pitfalls to Avoid

• Do not assume hematuria indicates complicated infection requiring broader spectrum antibiotics or longer duration therapy - treat as standard acute cystitis unless other features suggest upper tract involvement 1, 3
• Do not use fluoroquinolones as first-line therapy despite their high efficacy, as this promotes resistance to agents needed for serious infections 1, 2
• Do not prescribe trimethoprim-sulfamethoxazole empirically if local resistance exceeds 20% or if the patient used it in the previous 3 months 1, 2
• Do not obtain urine culture routinely unless symptoms fail to resolve within 2-4 weeks, atypical presentation, or suspicion for pyelonephritis 3, 4

When to Consider Alternative Diagnoses

If hematuria is severe or persistent despite appropriate antibiotic therapy, consider non-infectious causes such as:

• Hemorrhagic cystitis from other etiologies (chemical, radiation, malignancy) 6
• Eosinophilic cystitis 7
• These conditions require urologic evaluation and different management strategies 6