What is the appropriate management and first‑line antibiotic therapy for an otherwise healthy adult woman with acute cystitis presenting with hematuria?

Management of Acute Cystitis with Hematuria in Otherwise Healthy Adult Women

For an otherwise healthy adult woman presenting with acute cystitis and hematuria, initiate first-line antibiotic therapy with nitrofurantoin 100 mg twice daily for 5 days, trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (if local E. coli resistance is <20%), or fosfomycin 3 g single dose. 1, 2

Understanding Hematuria in Acute Cystitis

• Hematuria is a recognized symptom of acute uncomplicated cystitis and does not automatically indicate complicated infection or require different management than cystitis without hematuria 1
• The presence of hematuria alongside acute-onset dysuria, urgency, and frequency supports the diagnosis of acute cystitis 1
• Hematuria alone does not warrant routine cystoscopy or upper tract imaging in otherwise healthy women with typical cystitis symptoms 1

Pre-Treatment Diagnostic Approach

Obtain urine culture and sensitivity testing before initiating antibiotics in patients with recurrent UTIs, but this is not mandatory for first episodes of uncomplicated cystitis in otherwise healthy women. 1

• For women with recurrent UTIs (rUTIs), pre-treatment urine culture is essential to document microbial confirmation 1
• If the initial urine specimen suggests contamination, obtain a repeat specimen or consider catheterized collection 1

First-Line Antibiotic Selection

The choice among first-line agents should be guided by local antimicrobial resistance patterns and patient-specific factors:

Nitrofurantoin (Preferred in Many Settings)

• Dose: 100 mg twice daily for 5 days 2
• Minimizes antimicrobial resistance and does not share cross-resistance with commonly prescribed agents 3
• Safe during breastfeeding 2
• Should not be used in men due to inadequate tissue penetration 3

Trimethoprim-Sulfamethoxazole

• Dose: 160/800 mg twice daily for 3 days 2, 4
• Only appropriate if local E. coli resistance is <10-20% 5, 3
• More effective than beta-lactams regardless of treatment duration 6, 7
• Contraindicated in first trimester pregnancy 8

Fosfomycin Trometamol

• Dose: 3 g single dose 2, 9, 4
• FDA-approved specifically for uncomplicated cystitis in women caused by E. coli and Enterococcus faecalis 9
• Convenient single-dose regimen improves adherence 4
• Not indicated for pyelonephritis or perinephric abscess 9

Agents to Avoid as First-Line Therapy

Fluoroquinolones should be reserved for more invasive infections and not used for simple cystitis due to serious safety warnings (tendinopathies, aortic aneurysms/dissections) and the need to preserve their effectiveness. 1, 2, 4

• Beta-lactams (amoxicillin-clavulanate, cephalexin, cefpodoxime) are less effective than guideline-recommended first-line agents and should be considered second-line 2, 5, 7
• Cephalosporins like cefadroxil (500 mg twice daily for 3 days) may be used only if local E. coli resistance is <20% 8, 2

Treatment Duration Principles

Three-day regimens are more effective than single-dose therapy for most antimicrobials, while 5-7 day courses are appropriate for nitrofurantoin. 5, 6, 7

• Single-dose therapy is generally less effective than longer duration treatment 5, 6
• Treatment duration should be as short as reasonable to minimize antimicrobial resistance, generally no longer than 7 days 1

Patient-Initiated Treatment Option

For select patients with documented recurrent UTIs, consider patient-initiated (self-start) treatment while awaiting urine cultures. 1

• This approach requires prior documentation of positive cultures with symptomatic episodes 1
• Patients must be reliable and understand when to seek further medical attention 1

When to Obtain Urine Culture

Obtain pre-treatment urine culture if: 2

• Suspected acute pyelonephritis (fever, flank pain, systemic symptoms)
• Atypical symptoms that don't clearly indicate cystitis
• Symptoms not resolving or recurring within 4 weeks after treatment
• History of resistant organisms
• Recurrent UTIs requiring documentation 1

Critical Pitfalls to Avoid

• Do not routinely obtain post-treatment urine cultures in asymptomatic patients 2
• Do not treat asymptomatic bacteriuria 1
• Do not perform cystoscopy or upper tract imaging routinely for uncomplicated cystitis with hematuria 1
• Avoid fluoroquinolones for simple cystitis to preserve their effectiveness and minimize serious adverse effects 1, 2, 4
• Do not use beta-lactams as first-line empiric therapy due to inferior effectiveness 2, 6, 7

Antimicrobial Stewardship Considerations

Combine knowledge of your local antibiogram with selection of antimicrobial agents that have the least impact on normal vaginal and fecal flora. 1

• Regional antimicrobial resistance patterns vary significantly and should guide empiric therapy selection 1, 3
• Inappropriate treatment and broad-spectrum antibiotic overuse drive increasing fluoroquinolone and cephalosporin resistance 1