What is the recommended treatment for a patient with uncomplicated cystitis, considering factors such as symptoms, underlying medical conditions like diabetes, and potential for recurrent infections?

Treatment of Uncomplicated Cystitis

For premenopausal, nonpregnant women with uncomplicated cystitis, use nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days as first-line therapy. 1, 2

Defining Uncomplicated vs. Complicated Cystitis

Uncomplicated cystitis is limited to premenopausal, nonpregnant women without urological abnormalities or comorbidities, with no fever, flank pain, or signs of pyelonephritis. 2 These patients can be treated with short-course antibiotics (3-5 days). 2

Complicated cystitis includes all other patients—men, postmenopausal women, pregnant women, and those with anatomical abnormalities, immunosuppression, or diabetes—and requires longer treatment durations (7-14 days). 2 This is a critical distinction that fundamentally changes management.

Special Note on Diabetes

Women with diabetes presenting with acute cystitis should be treated similarly to women without diabetes if they have no voiding abnormalities. 3 The presence of diabetes alone does not automatically make cystitis "complicated" in terms of antibiotic choice, though treatment duration may need to be extended to 7 days. 2

First-Line Treatment for Uncomplicated Cystitis

Nitrofurantoin (Preferred)

• Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is the preferred first-line agent due to minimal resistance, limited collateral damage, and clinical cure rates of 88-93%. 1, 2
• This agent has bacterial cure rates of 81-92% and shows similar efficacy to ciprofloxacin (93% vs 95%). 1

Trimethoprim-Sulfamethoxazole (Conditional First-Line)

• TMP-SMX 160/800 mg (one double-strength tablet) twice daily for 3 days is appropriate ONLY when local resistance rates are known to be <20% or the infecting strain is confirmed susceptible. 1, 2, 4
• This 20% threshold is critical: clinical cure rates drop dramatically from 84-88% for susceptible strains to only 41-54% for resistant strains. 1
• If local resistance patterns are unknown, do not use TMP-SMX empirically. 1

Fosfomycin (Alternative First-Line)

• Fosfomycin trometamol 3 g single dose is an appropriate alternative with minimal resistance, though it has slightly inferior efficacy (clinical cure ~90%, microbiological cure 78%) compared to nitrofurantoin (86%). 1, 2
• This is particularly useful for patients with sulfa allergies. 1

Second-Line and Alternative Agents

Fluoroquinolones (Reserve for Complicated Cases)

• Fluoroquinolones (ciprofloxacin, levofloxacin) 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, 3
• These should be preserved for more serious infections like pyelonephritis. 1

β-Lactam Agents (Use Only When First-Line Cannot Be Used)

• β-lactam agents (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) in 3-7 day regimens should be used only when first-line agents cannot be used, as they generally have inferior efficacy and more adverse effects. 1, 3

Agents to Avoid

• Never use amoxicillin or ampicillin empirically due to poor efficacy and high prevalence of antimicrobial resistance worldwide. 1

Treatment for Complicated Cystitis and Special Populations

Men with Cystitis

Men require fundamentally different treatment than women and should NOT receive short-course regimens. 5

• 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. 5
• Alternative: TMP-SMX 160/800 mg twice daily for 7-14 days (only if local resistance <20%). 5
• Do NOT use: nitrofurantoin 5-day courses, fosfomycin single-dose, or pivmecillinam short courses—these are inadequate for male cystitis. 5

Women with Diabetes (Without Voiding Abnormalities)

• Treat with the same first-line agents as uncomplicated cystitis (nitrofurantoin 100 mg twice daily for 5 days). 3
• Consider extending duration to 7 days based on clinical judgment. 2

Postmenopausal Women

• Treat as complicated cystitis with 7-14 day durations. 2
• Obtain urine culture with susceptibility testing before initiating therapy. 2

Recurrent Urinary Tract Infections

For patients with recurrent UTIs (rUTIs):

• Obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment. 6
• Use first-line therapy (nitrofurantoin, TMP-SMX, fosfomycin) dependent on the local antibiogram. 6
• Treat acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than seven days. 6
• Patient-initiated treatment (self-start treatment) may be offered to select rUTI patients while awaiting urine cultures. 6

Asymptomatic Bacteriuria

• Do NOT treat asymptomatic bacteriuria in patients, including those with diabetes. 6
• Omit surveillance urine testing in asymptomatic patients with rUTIs. 6
• The only exceptions are pregnant women and patients scheduled for invasive urinary tract procedures. 6

Monitoring and Follow-Up

• Symptoms should improve within 48-72 hours of appropriate therapy. 2, 5
• If symptoms persist or worsen, obtain urine culture with susceptibility testing and consider retreatment with a 7-day regimen using another agent. 2
• Routine post-treatment urinalysis or cultures are NOT indicated for asymptomatic patients. 2
• For women whose symptoms do not resolve by end of treatment or recur within 2 weeks, obtain urine culture and susceptibility testing. 2

Common Pitfalls to Avoid

• Do not use fluoroquinolones as first-line therapy despite their high efficacy—this promotes resistance to agents needed for more serious infections. 1, 7
• Do not prescribe treatment durations longer than recommended—a study found 82% of TMP-SMX prescriptions, 73% of nitrofurantoin prescriptions, and 71% of fluoroquinolone prescriptions exceeded guideline-recommended durations. 7
• Do not treat men with short-course regimens (3-5 days) designed for uncomplicated cystitis in women. 5
• Do not assume all patients with diabetes have complicated cystitis—those without voiding abnormalities can be treated similarly to women without diabetes. 3
• Do not use TMP-SMX empirically without knowing local resistance patterns—if resistance exceeds 20%, efficacy drops dramatically. 1, 8