What is the treatment for uncomplicated cystitis?

Treatment of Uncomplicated Cystitis

Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is the recommended first-line treatment for uncomplicated cystitis in women. 1

First-Line Treatment Options

The Infectious Diseases Society of America (IDSA) prioritizes three agents as first-line therapy based on minimal resistance patterns and limited collateral damage 1:

• Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days achieves clinical cure rates of 88-93% and bacterial cure rates of 81-92% 2, 1
• Fosfomycin trometamol 3 g as a single dose demonstrates clinical cure rates of approximately 91%, though microbiological cure rates are slightly lower at 78-80% compared to nitrofurantoin's 86% 2, 1
• Pivmecillinam 400 mg twice daily for 3-7 days is recommended where available (primarily Europe, not available in North America) with clinical cure rates of 73% and bacterial cure rates of 79% 2, 1

When to Use Trimethoprim-Sulfamethoxazole

Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days should ONLY be used when local E. coli resistance rates are documented to be <20% or when the infecting organism is confirmed susceptible. 1, 3

• Clinical cure rates are 90-100% for susceptible organisms but drop dramatically to 41-54% when organisms are resistant 2, 3
• Patients who have used trimethoprim-sulfamethoxazole in the preceding 3-6 months or traveled outside the United States recently should avoid this agent due to increased resistance risk 3
• Common side effects include rash, urticaria, nausea, vomiting, and hematologic abnormalities 2

Alternative Treatment Options (Second-Line)

Fluoroquinolones should be reserved as alternative agents and NOT used as first-line therapy despite their high efficacy. 1

• Ciprofloxacin, levofloxacin, ofloxacin, and norfloxacin in 3-day regimens achieve clinical cure rates of 90-98% 2, 1
• These agents cause significant collateral damage by promoting resistance to drugs needed for more serious infections like pyelonephritis 1, 3
• Reserve fluoroquinolones for when first-line agents cannot be used 1

β-Lactam agents (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) in 3-7 day regimens are inferior to first-line options with clinical cure rates of 79-98% and bacterial cure rates of 74-98%, plus higher adverse effect rates 2, 1

Treatments to Avoid

• Amoxicillin or ampicillin should NEVER be used for empirical treatment due to poor efficacy and high worldwide resistance rates 1

Special Populations and Situations

For patients with sulfa allergies:

• Use nitrofurantoin as first choice 1
• Fosfomycin is an appropriate alternative 1
• Consider fluoroquinolones only if both first-line options are unavailable 1

For patients with penicillin allergies:

• Nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (if no sulfa allergy) remain appropriate 1

Avoid nitrofurantoin if early pyelonephritis is suspected as it does not achieve adequate tissue concentrations 4

Common Pitfalls to Avoid

• Do not use fluoroquinolones as first-line therapy simply because they are highly effective—this promotes resistance for more serious infections 1, 3
• Do not prescribe trimethoprim-sulfamethoxazole empirically without knowing local resistance patterns or recent antibiotic exposure 1, 3
• Do not extend treatment duration beyond recommended courses (5-7 days for nitrofurantoin, 3 days for trimethoprim-sulfamethoxazole or fluoroquinolones) as each additional day increases adverse event risk by 5% without added benefit 3
• Do not order routine post-treatment urine cultures in asymptomatic patients 4

Follow-Up Recommendations

• For women whose symptoms do not resolve by end of treatment or recur within 2 weeks, obtain urine culture with susceptibility testing 4
• Consider retreatment with a 7-day regimen using a different agent if symptoms persist 4