What is the treatment for cystitis (inflammation of the urinary bladder)?

From the Guidelines

To treat cystitis, start with antibiotics such as nitrofurantoin (100mg twice daily for 5 days), trimethoprim-sulfamethoxazole (160/800mg twice daily for 3 days), or fosfomycin (3g single dose) as recommended by the most recent guidelines 1. While taking antibiotics, drink plenty of water (at least 2-3 liters daily) to help flush bacteria from the urinary tract. Over-the-counter pain relievers like ibuprofen (400mg every 6-8 hours) or acetaminophen (500mg every 6 hours) can help manage pain and discomfort. Apply a heating pad to the lower abdomen for additional pain relief. Avoid caffeine, alcohol, and spicy foods which can irritate the bladder. If symptoms don't improve within 48 hours of starting antibiotics, or if you develop fever, back pain, or blood in urine, seek immediate medical attention as this could indicate a kidney infection. For recurrent cystitis, preventive measures include urinating after sexual intercourse, wiping from front to back after using the toilet, and staying well-hydrated. Antibiotics work by killing the bacteria (usually E. coli) that cause the infection, while increased fluid intake helps dilute urine and flush out bacteria before they can attach to the bladder wall. The choice of antibiotic should be based on local resistance patterns and the patient's medical history, as suggested by the Infectious Diseases Society of America (IDSA) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines 1. It is essential to note that fluoroquinolones, although highly efficacious, should be reserved for patients with a history of resistant organisms due to their high propensity for adverse effects 1. In cases where the patient has a history of resistant organisms, alternative antibiotics such as pivmecillinam or beta-lactam agents may be considered, but their use should be guided by susceptibility testing and clinical judgment 1. Ultimately, the goal of treatment is to alleviate symptoms, prevent complications, and improve quality of life, while also minimizing the risk of antibiotic resistance and adverse effects.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to empiric selection of therapy Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris

Treatment of cystitis can be done with trimethoprim-sulfamethoxazole (PO) 2 for the treatment of urinary tract infections due to susceptible strains of certain organisms.

• The drug is effective against Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris.
• Phenazopyridine (PO) 3 can be used for the symptomatic relief of pain, burning, urgency, frequency, and other discomforts arising from irritation of the lower urinary tract mucosa caused by infection.
• However, phenazopyridine (PO) should not be used for more than 2 days and should be discontinued when symptoms are controlled.

From the Research

Treatment Options for Cystitis

• The Infectious Diseases Society of America has published guidelines for the treatment of uncomplicated cystitis, recommending 3 days of trimethoprim/sulfamethoxazole (TMP/SMZ) or trimethoprim alone as standard therapy in regions where less than 10% to 20% of Escherichia coli are resistant to TMP/SMZ 4.
• In regions with higher resistance rates, oral fluoroquinolones for 3 days are recommended, with alternatives such as nitrofurantoin for 7 days or fosfomycin as single-dose therapy also considered 4.
• A 5-day course of nitrofurantoin has been shown to be equivalent to a 3-day course of trimethoprim-sulfamethoxazole in treating acute uncomplicated cystitis in women 5.
• Other treatment options for acute uncomplicated cystitis include a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 6.

Antibiotic Resistance and Treatment

• The increasing prevalence of antibiotic-resistant uropathogens affects the diagnosis and management of urinary tract infections, with high rates of resistance to trimethoprim-sulfamethoxazole and ciprofloxacin in some communities 6, 7.
• Second-line treatment options for urinary tract infections include oral cephalosporins, fluoroquinolones, and β-lactams such as amoxicillin-clavulanate 6.
• Treatment options for urinary tract infections caused by extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae include nitrofurantoin, fosfomycin, pivmecillinam, and fluoroquinolones 6.

Specific Patient Populations

• Women with diabetes without voiding abnormalities can be treated similarly to women without diabetes for acute cystitis, with immediate antimicrobial therapy recommended 7.
• Men with acute urinary tract infections may require 7 to 14 days of therapy, although limited data are available to support this recommendation 7.