What is the treatment for acute cystitis in patients with Chronic Kidney Disease (CKD)?

Treatment of Acute Cystitis in CKD Patients

For patients with CKD and acute cystitis, nitrofurantoin (100 mg twice daily for 5 days) is the first-line treatment when eGFR is >30 mL/min, while fosfomycin trometamol (3 g single dose) becomes the preferred option when eGFR is <30 mL/min. 1

Treatment Algorithm Based on Renal Function

For eGFR >30 mL/min:

• First-line: Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days 2, 1
• Alternative: Trimethoprim-sulfamethoxazole 160/800 mg (1 double-strength tablet) twice daily for 3 days, but only if local resistance rates do not exceed 20% or if the infecting strain is known to be susceptible 2
• Alternative: Fosfomycin trometamol 3 g as a single oral dose 2, 1

For eGFR <30 mL/min:

• Preferred: Fosfomycin trometamol 3 g single dose 1
• Nitrofurantoin should be avoided in this population due to reduced efficacy and increased risk of toxicity 1

Essential Pre-Treatment Steps

• Always obtain urine culture and susceptibility testing before initiating therapy in CKD patients, as this complicated population requires culture-directed treatment 2, 1
• Tailor initial empirical therapy based on culture results once available 2

Second-Line Options When First-Line Agents Cannot Be Used

• Fluoroquinolones (ciprofloxacin 500 mg twice daily for 7 days or levofloxacin) are highly efficacious but should be reserved for situations where first-line agents cannot be used due to concerns about collateral damage and resistance 2, 1
• β-lactam agents including amoxicillin-clavulanate, cefdinir, cefaclor, or cefpodoxime-proxetil for 3-7 days are appropriate when other recommended agents cannot be used, though they have inferior efficacy and more adverse effects 2, 1
• Cephalexin may be appropriate in certain settings but is less well studied 2

Treatment Duration

• Treat acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than 7 days 2
• For standard first-line agents: nitrofurantoin 5 days, trimethoprim-sulfamethoxazole 3 days, fosfomycin single dose 2

Critical Pitfalls to Avoid

• Do not use nitrofurantoin when eGFR is <30 mL/min as this leads to treatment failure and increased toxicity 1
• Do not use amoxicillin or ampicillin for empirical treatment given poor efficacy and very high prevalence of antimicrobial resistance worldwide 2
• Do not fail to adjust antibiotic dosing based on degree of renal impairment, as this can lead to treatment failure or increased toxicity 1
• Do not treat asymptomatic bacteriuria in CKD patients, as this does not improve outcomes 2

Special Considerations for CKD Patients

• The general management of uncomplicated UTIs in CKD follows the same principles as the general population, with modifications based on renal function 2
• Fosfomycin provides adequate urinary concentrations without requiring dose adjustment for renal impairment, with clinical cure rates of 90-91% 1
• In patients with ADPKD specifically, the same first-line therapies (nitrofurantoin, trimethoprim-sulfamethoxazole, fosfomycin) apply based on local antimicrobial susceptibility profiles 2

Resistance Considerations

• The 20% resistance threshold for trimethoprim-sulfamethoxazole is based on expert opinion derived from clinical, in vitro, and mathematical modeling studies 2
• Local resistance rates should guide empirical antimicrobial decisions, as hospital antibiograms may not accurately reflect community-acquired uncomplicated infections 2
• Nitrofurantoin, fosfomycin, and pivmecillinam (where available) have minimal resistance and propensity for collateral damage 2