What is the recommended treatment for acute cystitis?

Acute Cystitis Management

First-Line Treatment for Women with Uncomplicated Cystitis

Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is the preferred first-line therapy for acute uncomplicated cystitis in women, offering clinical cure rates of 88-93% with minimal resistance and collateral damage. 1

Primary Treatment Options

The Infectious Diseases Society of America identifies three first-line agents for acute uncomplicated cystitis in premenopausal, non-pregnant women 1:

• Nitrofurantoin monohydrate/macrocrystals: 100 mg twice daily for 5 days, with bacterial cure rates of 81-92% 1
• Trimethoprim-sulfamethoxazole (Bactrim DS): 160/800 mg twice daily for 3 days, but ONLY when local E. coli resistance is confirmed <20% or susceptibility is documented 1, 2
• Fosfomycin trometamol: 3 g single dose, with clinical cure rates around 90%, though microbiological cure may be slightly lower (78%) compared to nitrofurantoin (86%) 1

Critical Decision Point: When to Avoid Trimethoprim-Sulfamethoxazole

Do not use trimethoprim-sulfamethoxazole empirically if: 2

• Local E. coli resistance exceeds 20% (clinical cure drops to 41-54% for resistant strains versus 84-88% for susceptible strains) 1, 2
• Patient used trimethoprim-sulfamethoxazole in the preceding 3-6 months 2
• Patient traveled outside the United States in the preceding 3-6 months 2
• Patient has sulfa allergy 1

Alternative Agents (Second-Line)

Fluoroquinolones should be reserved as alternative agents despite their high efficacy, due to concerns about collateral damage and the need to preserve them for more serious infections: 1

• Ciprofloxacin, levofloxacin, ofloxacin, or norfloxacin: 3-day regimens are highly effective but should only be used when first-line agents cannot be used 1, 3

β-Lactam agents have inferior efficacy and should only be used when first-line agents are contraindicated: 1

• Amoxicillin-clavulanate, cefdinir, cefaclor, or cefpodoxime-proxetil for 3-7 days 1
• These agents generally have more adverse effects compared to first-line options 1

Agents to Avoid

Never use amoxicillin or ampicillin for empirical treatment due to poor efficacy and high worldwide resistance rates. 1

Treatment for Men with Cystitis

Cystitis in males requires fundamentally different treatment than in women and should NEVER be treated with short-course regimens (3-5 days) used for uncomplicated cystitis in women. 4

First-Line Treatment for Male Cystitis

Fluoroquinolones are the preferred empiric choice for male cystitis due to excellent prostatic penetration: 4

• Ciprofloxacin: 500 mg twice daily for 7 days 4
• Levofloxacin: 500-750 mg once daily for 7 days 4

Alternative Options for Men

• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 7-14 days (only if local resistance <20% or susceptibility confirmed) 4
• β-lactams with good urinary penetration: Amoxicillin-clavulanate, cefdinir, or cefpodoxime-proxetil for 7-14 days 4

Agents That Are Inadequate for Male Cystitis

Do not use these short-course regimens in men: 4

• Nitrofurantoin 5-day courses 4
• Fosfomycin single-dose therapy 4
• Pivmecillinam short courses 4

Special Populations

Patients with Sulfa and Penicillin Allergies

For patients with both sulfa and penicillin allergies, fosfomycin trometamol 3 g single dose is the most appropriate first-line alternative. 1

If fosfomycin is unavailable, consider fluoroquinolones (ciprofloxacin or levofloxacin) for 3 days, recognizing their limitations 1

Women with Diabetes

Women with diabetes who have no voiding abnormalities should be treated identically to women without diabetes using the same first-line agents and durations. 3

Pregnancy Considerations

Avoid trimethoprim-sulfamethoxazole in the last trimester of pregnancy. 2

Treatment Monitoring

Symptoms should improve within 48-72 hours of initiating appropriate therapy. 4

If symptoms persist or worsen, obtain urine culture with susceptibility testing 4

Common Pitfalls to Avoid

• Prescribing treatment durations longer than recommended: Each additional day beyond recommended duration carries a 5% increased risk for antibiotic-associated adverse events without additional benefits 2
• Using fluoroquinolones as first-line therapy in women: Despite high efficacy, this promotes resistance to agents needed for more serious infections 1
• Treating male cystitis with short-course regimens: Men require 7-14 day courses, not the 3-5 day regimens used in women 4
• Relying on hospital antibiograms for community UTI: Hospital antibiograms often overestimate community resistance rates; local outpatient surveillance data is more accurate 2