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 but without voiding abnormalities should be treated similarly to women without diabetes. 3 The presence of diabetes alone does not automatically make cystitis "complicated" if there are no other complicating factors. 3

First-Line Treatment for Uncomplicated Cystitis (Premenopausal Women)

Primary Recommendation

• 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, 4

Alternative First-Line Options

• Trimethoprim-sulfamethoxazole 160/800 mg 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 This 20% threshold is critical because clinical cure rates drop dramatically with resistant strains (41-54% vs 84-88% for susceptible strains). 1

• Fosfomycin trometamol 3 g single dose is an appropriate alternative with minimal resistance, though it has slightly inferior microbiological cure rates (78% vs 86% for nitrofurantoin). 1, 2

Second-Line Options (Reserve for When First-Line Cannot Be Used)

• Fluoroquinolones (ciprofloxacin, levofloxacin) for 3 days are highly effective but should be reserved as alternative agents due to collateral damage and the need to preserve them for more serious infections. 1, 2

• β-Lactam agents (amoxicillin-clavulanate, cefdinir, cefpodoxime-proxetil) for 3-7 days have inferior efficacy and more adverse effects compared to first-line options. 1

Agents to Avoid

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

Treatment for Complicated Cystitis

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. 2, 5

• Nitrofurantoin 5-day courses, fosfomycin single-dose, and pivmecillinam short courses are all inadequate for male cystitis. 5

• Alternative options include trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7-14 days (only if local resistance <20%) or β-lactams with good urinary penetration for 7-14 days. 5

Women with Diabetes (Without Voiding Abnormalities)

• Treat the same as uncomplicated cystitis in premenopausal women: nitrofurantoin 100 mg twice daily for 5 days. 3

• If voiding abnormalities are present, treat as complicated cystitis with 7-14 day regimens. 2

Other Complicated Populations

• Treatment duration should be 7-14 days rather than 3-5 days. 2
• Obtain urine culture with susceptibility testing before initiating therapy. 2

Recurrent UTI Management

Diagnostic Approach

• Obtain urinalysis, urine culture, and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with recurrent UTIs. 6

• Patient-initiated treatment (self-start) may be offered to select recurrent UTI patients while awaiting culture results. 6

Treatment Principles

• Use first-line therapy (nitrofurantoin, trimethoprim-sulfamethoxazole, 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

• For cultures resistant to oral antibiotics, culture-directed parenteral antibiotics may be used for as short a course as reasonable, generally no longer than seven days. 6

Asymptomatic Bacteriuria

• Do NOT perform surveillance urine testing in asymptomatic patients with recurrent UTIs. 6

• Do NOT treat asymptomatic bacteriuria except in pregnant women and patients scheduled for invasive urinary tract procedures. 6 Women with diabetes and long-term care facility residents do not benefit from treatment of asymptomatic bacteriuria. 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 and consider retreatment with a 7-day regimen using another agent. 2

• For women whose symptoms do not resolve by end of treatment or recur within 2 weeks, obtain urine culture and susceptibility testing. 2

• Routine post-treatment urinalysis or cultures are NOT indicated for asymptomatic patients. 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

• Do not prescribe trimethoprim-sulfamethoxazole empirically if local resistance rates are ≥20% or unknown. 1, 2

• Do not treat men with short-course regimens (3-5 days) designed for uncomplicated cystitis in women. 5

• Do not prescribe treatment durations longer than recommended—a common problem in practice where 73-82% of prescriptions exceed guideline-recommended durations. 7

• Do not treat asymptomatic bacteriuria in non-pregnant patients or those not undergoing urinary procedures. 6