What is the recommended treatment for a patient diagnosed with cystitis?

Treatment of Cystitis

For acute uncomplicated cystitis in premenopausal, non-pregnant women, nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is the recommended first-line treatment due to minimal resistance patterns and excellent efficacy. 1

Treatment Algorithm for Women with Uncomplicated Cystitis

First-Line Options (in order of preference):

• Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is the preferred agent with clinical cure rates of 88-93% and bacterial cure rates of 81-92%, comparable to fluoroquinolones and trimethoprim-sulfamethoxazole 1, 2

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days should only be used when local E. coli resistance rates are documented to be <20% or susceptibility is confirmed 1, 3, 2

• Fosfomycin trometamol 3 g single dose is an appropriate alternative with clinical cure rates of approximately 90%, though microbiological cure rates may be slightly lower (78%) compared to nitrofurantoin (86%) 1, 2

Alternative Options (when first-line agents cannot be used):

• Fluoroquinolones (ciprofloxacin, levofloxacin) for 3 days are highly effective but should be reserved for more serious infections due to concerns about promoting antimicrobial resistance and collateral damage 1, 2

• β-Lactam agents (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) for 3-7 days have inferior efficacy compared to first-line options and should only be used when other agents are contraindicated 1, 2

Agents to Avoid:

• Amoxicillin or ampicillin monotherapy should never be used empirically due to poor efficacy and high worldwide resistance rates 1

Treatment of Cystitis in Males

Male cystitis requires fundamentally different treatment than female uncomplicated cystitis and should NOT be treated with short-course regimens (3-5 days). 4

First-Line Treatment for Men:

• 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 4

• Fluoroquinolones remain appropriate for male cystitis despite concerns about their use in female uncomplicated cystitis 4

Alternative Options for Men:

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7-14 days (only if local resistance <20% or susceptibility confirmed) 4

• β-Lactams with good urinary penetration (amoxicillin-clavulanate, cefdinir, cefpodoxime-proxetil) for 7-14 days 4

Agents That Are Inadequate for Male Cystitis:

• Nitrofurantoin 5-day courses are insufficient 4
• Fosfomycin single-dose therapy is inadequate 4
• Pivmecillinam short courses are not appropriate 4

Special Populations: Patients with Drug Allergies

For Penicillin Allergy:

• Nitrofurantoin 100 mg twice daily for 5 days remains the first-line choice 5

• Fosfomycin 3 g single dose is the second-line option 5

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days is third-line (only if local resistance <20% and no sulfa allergy) 5

For Both Penicillin AND Sulfa Allergies:

• Nitrofurantoin and fosfomycin are the preferred options 1

• If both are unavailable, consider fluoroquinolones (ciprofloxacin, levofloxacin) for 3 days, though this should be avoided when possible due to resistance concerns 1

Critical Clinical Considerations

Resistance Patterns:

• The 20% resistance threshold for trimethoprim-sulfamethoxazole is based on expert consensus from clinical, in vitro, and mathematical modeling studies 1

• Trimethoprim-sulfamethoxazole shows dramatically reduced efficacy against resistant organisms (clinical cure rates of 41-54% for resistant strains versus 84-88% for susceptible strains) 1

• Local resistance patterns should guide empiric therapy selection 1, 2

Treatment Monitoring:

• Symptoms should improve within 48-72 hours of initiating appropriate therapy 4

• Routine post-treatment urinalysis or urine cultures are NOT indicated for asymptomatic patients 5

• For women whose symptoms do not resolve by end of treatment or recur within 2 weeks, obtain urine culture with antimicrobial susceptibility testing 5

• If symptoms persist or worsen, retreatment with a 7-day regimen using another agent should be considered 5

Common Pitfalls to Avoid

• Do not use fluoroquinolones as first-line therapy in women despite their high efficacy, as this promotes resistance to agents needed for more serious infections 1

• Do not treat male cystitis with short-course regimens designed for female uncomplicated cystitis 4

• Do not prescribe trimethoprim-sulfamethoxazole empirically without knowing local resistance patterns or in patients with sulfa allergies 1

• Do not use amoxicillin or ampicillin empirically due to high resistance rates worldwide 1, 4

• Do not use nitrofurantoin or fosfomycin short courses in men as they are inadequate for male urinary tract infections 4