What is the treatment for cystitis symptoms?

Treatment of Acute Uncomplicated Cystitis

Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is the optimal first-line treatment for acute uncomplicated cystitis, offering excellent efficacy with minimal resistance and collateral damage. 1

First-Line Antibiotic Options

The choice of empirical therapy depends on local resistance patterns and drug availability:

Preferred First-Line Agents

• Nitrofurantoin monohydrate/macrocrystals: 100 mg twice daily for 5 days is highly effective with minimal resistance and collateral damage 1, 2

• Trimethoprim-sulfamethoxazole (TMP-SMX): 160/800 mg (1 double-strength tablet) twice daily for 3 days is appropriate only if local E. coli resistance rates do not exceed 20% or if the infecting strain is known to be susceptible 1, 2

  • The 20% resistance threshold is based on expert opinion from clinical, in vitro, and mathematical modeling studies 1
  • In some regions, trimethoprim alone (100 mg twice daily for 3 days) is considered equivalent 1

• Fosfomycin trometamol: 3 g single dose offers minimal resistance and collateral damage but has inferior efficacy compared to standard short-course regimens according to FDA data 1, 2

Alternative Agents (When First-Line Cannot Be Used)

• Fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin): Highly efficacious in 3-day regimens but have significant propensity for collateral damage and should be reserved for more invasive infections rather than simple cystitis 1, 2

• β-Lactam agents (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil): 3-7 day regimens are appropriate only when other recommended agents cannot be used, as they have inferior efficacy and more adverse effects compared to other UTI antimicrobials 1, 2

• Amoxicillin or ampicillin should NOT be used for empirical treatment due to poor efficacy and very high worldwide resistance rates 1

Critical Treatment Considerations

Duration of Therapy

Treat acute cystitis episodes with as short a duration as reasonable, generally no longer than 7 days 1

• 3-day regimens are standard for TMP-SMX and fluoroquinolones 1
• 5-7 day regimens for nitrofurantoin 1, 2
• Single-dose for fosfomycin 1

When to Withhold Immediate Antibiotics

Recent 2024 guidelines suggest against withholding antibiotics in patients presenting with provisional cystitis diagnosis, despite evidence that 30-50% may achieve symptom resolution without antibiotics 1

• The risk of pyelonephritis is significantly higher without immediate antibiotics (3.6% vs 0.4%, OR 5.6) 1
• NSAIDs or delayed prescriptions reduce antibiotic consumption but increase symptom burden and pyelonephritis risk 1
• This data applies primarily to healthy, non-pregnant women in primary care settings 1

Diagnostic Approach

When Urine Culture Is NOT Needed

• Urinalysis alone (without culture) is sufficient for diagnosing acute uncomplicated cystitis in healthy, non-pregnant women with typical symptoms (dysuria, frequency, urgency) 3, 2
• Acute uncomplicated cystitis can be diagnosed without an office visit in appropriate patients 2

When Urine Culture IS Required

Obtain urine culture and sensitivity before treatment in patients with: 1

• Recurrent UTIs (≥3 episodes in 12 months or ≥2 in 6 months) 1
• Suspected pyelonephritis 1, 3
• Symptoms that do not resolve or recur within 2-4 weeks after treatment 3
• Atypical symptoms 3
• Pregnancy 4
• Diabetes or other comorbidities 5

Post-Treatment Management

Follow-Up Testing

Do NOT perform routine post-treatment urine cultures in asymptomatic patients 4

• Focus on clinical response rather than laboratory confirmation of bacterial eradication 4
• Post-treatment culture is indicated only if symptoms persist or recur after treatment completion 4

Asymptomatic Bacteriuria

Do NOT treat asymptomatic bacteriuria detected on routine testing 1, 4

• Treatment of asymptomatic bacteriuria contributes to antibiotic overuse and resistance 4
• Exceptions: pregnant patients and before urological procedures that breach the mucosa 4

Common Pitfalls to Avoid

• Avoid using fluoroquinolones as first-line therapy for simple cystitis—reserve them for pyelonephritis and complicated infections 1, 2
• Do not use β-lactams as first-line empirical therapy due to inferior efficacy 1, 2
• Check local antibiograms before prescribing TMP-SMX empirically, as resistance rates vary geographically 1
• Avoid treating positive urine cultures in asymptomatic patients, which drives resistance 4
• Do not prescribe unnecessarily long courses—3-5 days is sufficient for uncomplicated cystitis 1