From the Guidelines
The first line treatment for uncomplicated cystitis in women is a short course of antibiotics, with nitrofurantoin (100mg twice daily for 5 days), trimethoprim-sulfamethoxazole (160/800mg twice daily for 3 days), or fosfomycin (3g single dose) being the preferred options, as recommended by the most recent guidelines 1.
Key Considerations
- The choice of antibiotic should be based on local resistance patterns and patient-specific factors, such as allergy history and potential side effects.
- Nitrofurantoin is often chosen first due to its lower resistance rates and minimal impact on gut flora, as noted in the 2021 American College of Physicians guidelines 1.
- Fosfomycin is a suitable alternative, particularly for patients who cannot tolerate other options, as it has a high efficacy rate and a low risk of resistance, according to the 2024 European Urology guidelines 1.
Implementation
- Patients should complete the entire antibiotic course, even if symptoms improve quickly, to ensure complete eradication of the infection.
- Drinking plenty of fluids can help flush bacteria from the urinary tract and reduce the risk of recurrence.
- Phenazopyridine (Pyridium) 100-200mg three times daily for 1-2 days can be used to alleviate urinary pain, if necessary.
Monitoring and Follow-up
- Symptoms typically improve within 1-2 days of starting treatment, but patients should seek follow-up care if symptoms persist or recur shortly after completing antibiotics, as this may indicate antibiotic resistance or a complicated infection requiring different management, as advised by the American College of Physicians 1.
From the FDA Drug Label
Fosfomycin tromethamine granules for oral solution is indicated only for the treatment of uncomplicated urinary tract infections (acute cystitis) in women due to susceptible strains of Escherichia coli and Enterococcus faecalis. The first line treatment for uncomplicated cystitis in women is fosfomycin tromethamine granules for oral solution 2.
- The recommended dosage is one sachet for women 18 years of age and older 2.
- Fosfomycin is indicated for the treatment of uncomplicated urinary tract infections (acute cystitis) in women due to susceptible strains of Escherichia coli and Enterococcus faecalis 2.
From the Research
First-Line Treatment Options
- Fosfomycin, nitrofurantoin, and trimethoprim/sulfamethoxazole (in regions where the prevalence of Escherichia coli resistance does not exceed 20 percent) are recommended as first-line treatments for acute uncomplicated cystitis in women 3.
- A 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam are also recommended as first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females 4.
- Nitrofurantoin given for 7 days has a cure rate of 80-85%, and fosfomycin trometamol as a single dose has cure rates of 75-85% 5.
- A 5-day course of nitrofurantoin is equivalent clinically and microbiologically to a 3-day course of trimethoprim-sulfamethoxazole and should be considered an effective fluoroquinolone-sparing alternative for the treatment of acute cystitis in women 6.
Considerations for Treatment
- Local resistance data should be considered when choosing a treatment option, as the antimicrobial susceptibility of community isolates of Escherichia coli evolves 5, 7.
- Non-antibiotic therapy and non-antimicrobial prophylactic strategies should also be discussed and offered to patients, especially those suffering from recurrent uncomplicated cystitis 7.
- Individual risk factors and possible behavioral changes should be taken into account in patients suffering from recurrent uncomplicated cystitis 7.