Management of Uncomplicated Bacterial Cystitis
First-Line Treatment for Women
Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is the preferred first-line therapy for acute uncomplicated cystitis in women, with clinical cure rates of 88-93% and minimal resistance patterns. 1
Primary Treatment Options
Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is recommended by the Infectious Diseases Society of America as first-line therapy due to minimal resistance and limited collateral damage, with efficacy comparable to trimethoprim-sulfamethoxazole 1
Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) should only be used when local resistance rates are confirmed to be <20% or the infecting strain is documented as susceptible 1, 2
Fosfomycin trometamol (3 g single dose) is an appropriate alternative first-line option with clinical cure rates of approximately 90%, though microbiological cure rates may be slightly lower (78%) compared to nitrofurantoin (86%) 1, 4
Pivmecillinam (400 mg twice daily for 3-7 days) is recommended in European countries where available, but is not available in North America 1
Alternative Treatment Options (When First-Line Agents Cannot Be Used)
Fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin, norfloxacin) are highly effective in 3-day regimens but should be reserved as alternative agents due to their propensity for collateral damage and promotion of resistance 1
- These should be preserved for more serious infections requiring their broad-spectrum coverage 1
β-Lactam agents (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) in 3-7 day regimens should only be used when first-line agents cannot be used, as they generally have inferior efficacy and more adverse effects 1
Treatments to Avoid
- Amoxicillin or ampicillin monotherapy should never be used for empirical treatment due to poor efficacy and high prevalence of antimicrobial resistance worldwide 1
Management in Patients with Penicillin and Sulfa Allergies
For patients allergic to both penicillin and sulfa drugs, nitrofurantoin remains first-line if renal function is adequate (eGFR >30 mL/min), followed by fosfomycin as the preferred alternative. 5
Treatment Algorithm for Allergic Patients
If eGFR >30 mL/min: Nitrofurantoin 100 mg twice daily for 5 days 5
If eGFR <30 mL/min: Fosfomycin trometamol 3 g single dose is preferred, as it provides adequate urinary concentrations without requiring dose adjustment for renal impairment 5
- Fosfomycin shows only 16.0% clinical failures in patients with eGFR <60 mL/min compared to 23.3% with nitrofurantoin 5
If both options are unavailable: Consider fluoroquinolones (ciprofloxacin 500 mg twice daily for 7 days or levofloxacin) for 3 days, recognizing their limitations 1, 5
Cephalosporins (cefdinir, cefaclor, cefpodoxime-proxetil) for 3-7 days can be considered, but patients with documented penicillin allergy (such as rash) should avoid cephalosporins without formal allergy testing due to 2-4% cross-reactivity 5
Management in Patients with Chronic Kidney Disease
Assess renal function first: if eGFR >30 mL/min, use nitrofurantoin; if eGFR <30 mL/min, fosfomycin becomes the mandatory choice. 5
Critical Considerations for CKD Patients
Nitrofurantoin must be avoided when eGFR is <30 mL/min due to reduced efficacy and increased risk of toxicity, as recommended by the National Kidney Foundation 5
- This is a common pitfall that leads to treatment failure and potential adverse events 5
Urine culture with susceptibility testing is strongly recommended before initiating therapy in CKD patients to guide appropriate antibiotic selection 5
Failing to adjust antibiotic dosing based on the degree of renal impairment can lead to treatment failure or increased toxicity 5
Management in Males
Cystitis in males requires 7-day fluoroquinolone therapy (ciprofloxacin 500 mg twice daily or levofloxacin 500-750 mg once daily) and should never be treated with short-course regimens used for women. 6
Key Distinctions for Male Cystitis
Male cystitis is fundamentally different from uncomplicated cystitis in women and should not be treated with the same short-course regimens 6
- Guidelines for "uncomplicated cystitis" (3-5 day regimens) apply only to premenopausal, non-pregnant women—not to men 6
Ciprofloxacin 500 mg twice daily for 7 days or levofloxacin 500-750 mg once daily for 7 days is the preferred empiric choice due to excellent prostatic penetration and coverage of common uropathogens 6
Fluoroquinolones remain appropriate for male cystitis despite concerns about collateral damage in female uncomplicated cystitis, as recommended by the Infectious Diseases Society of America 6
Alternative Options for Males
Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7-14 days (only if local resistance <20% or susceptibility confirmed) 6
β-lactams with good urinary penetration (amoxicillin-clavulanate, cefdinir, cefpodoxime-proxetil) for 7-14 days 6
Agents That Are Inadequate for Male Cystitis
- Nitrofurantoin 5-day courses are inadequate 6
- Fosfomycin single-dose therapy is insufficient 6, 4
- Pivmecillinam short courses are not appropriate 6
- Amoxicillin or ampicillin monotherapy should be avoided due to high resistance rates 6
Monitoring
- Symptoms should improve within 48-72 hours of initiating appropriate therapy 6
- If symptoms persist or worsen, obtain urine culture with susceptibility testing 6
Common Pitfalls to Avoid
Using trimethoprim-sulfamethoxazole empirically in areas where resistance exceeds 20% leads to treatment failure in over half of cases 1
Prescribing nitrofurantoin in patients with eGFR <30 mL/min results in inadequate urinary concentrations and increased toxicity risk 5
Treating male cystitis with short-course regimens (3-5 days) designed for women leads to treatment failure due to potential prostatic involvement 6
Using fluoroquinolones as first-line therapy in women promotes resistance to these important agents needed for more serious infections 1
Not obtaining urine cultures in CKD patients misses the opportunity to guide therapy in this complicated population 5
Failing to consider local resistance patterns when choosing empiric therapy can result in predictable treatment failures 1