Treatment of cystitis
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urinary tract infection uncomplicated complicated special populations
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Treatment of Cystitis
Cystitis is inflammation of the bladder, most commonly from bacterial infection (acute bacterial cystitis). Treatment is stratified by whether the infection is uncomplicated or complicated.
1. Classification
| Type | Definition |
|---|---|
| Uncomplicated | Healthy, non-pregnant female; normal urinary tract anatomy/function |
| Complicated | Male patient, pregnancy, structural/functional urinary tract abnormality, immunocompromise, indwelling catheter, recent instrumentation, nosocomial onset |
2. Uncomplicated Acute Bacterial Cystitis (Women)
First-Line Antibiotics
| Agent | Dose & Duration | Notes |
|---|---|---|
| Nitrofurantoin monohydrate/macrocrystals | 100 mg twice daily × 5 days | Preferred; minimal collateral damage to gut flora; avoid if eGFR <30 |
| Trimethoprim-sulfamethoxazole (TMP-SMX) | 160/800 mg twice daily × 3 days | Use only if local resistance <20% |
| Fosfomycin trometamol | 3 g single dose (oral) | Convenient; slightly lower efficacy than TMP-SMX in some trials |
| Pivmecillinam | 400 mg twice daily × 5–7 days | Available in Europe; not in USA |
Second-Line Antibiotics (use if first-line not suitable)
| Agent | Dose & Duration | Notes |
|---|---|---|
| Fluoroquinolones (ciprofloxacin, levofloxacin) | Cipro 250 mg BID × 3 days | Effective but reserved due to collateral damage, resistance, and adverse effects (tendinopathy, CNS) |
| Amoxicillin-clavulanate | 500/125 mg TID × 5–7 days | Lower cure rates; use when others not suitable |
| Cephalosporins (cephalexin, cefuroxime) | Varies × 3–7 days | Second-line; oral options |
3. Complicated Cystitis
Per the Guidance on the Treatment of Antimicrobial Resistant Gram-Negative Infections (p. 2), complicated UTI should generally be treated with agents and durations similar to pyelonephritis (7–14 days). However, if the source has been controlled (e.g., Foley catheter removed), therapy can be de-escalated to regimens appropriate for uncomplicated cystitis, counting day 1 from source control.
Empiric options (pending culture):
- Oral fluoroquinolone (if local susceptibility allows)
- TMP-SMX
- Adjust to targeted therapy once culture and sensitivity results available
4. Special Pathogens: Resistant Organisms
For cystitis caused by carbapenem-resistant Enterobacterales (CRE), per IDSA guidelines (Treatment of ESBL-E, CRE, and DTR-P. aeruginosa, p. 8):
- Preferred: Ciprofloxacin, levofloxacin, TMP-SMX, nitrofurantoin, or single-dose aminoglycoside (agent guided by susceptibility)
- Ertapenem-resistant, meropenem-susceptible CRE: Standard infusion meropenem
- If no preferred agents active: Ceftazidime-avibactam, meropenem-vaborbactam, imipenem-cilastatin-relebactam, or cefiderocol
For ESBL-producing organisms: Nitrofurantoin, TMP-SMX, or fosfomycin often retain activity and are preferred over carbapenems for uncomplicated cystitis when susceptible.
5. Special Populations
Pregnancy
- Safe agents: Nitrofurantoin (avoid at term, >36 weeks), cephalexin, amoxicillin-clavulanate, fosfomycin
- Avoid: TMP-SMX (1st trimester — folate antagonism; 3rd trimester — kernicterus risk), fluoroquinolones, tetracyclines
- Duration: 5–7 days; treat asymptomatic bacteriuria in pregnancy
- Test of cure urine culture recommended post-treatment
Males
- Any UTI in a male is considered complicated
- Evaluate for structural abnormality, prostatitis
- Treat for 7–14 days; fluoroquinolones preferred if prostate involvement suspected (good tissue penetration)
Catheter-Associated UTI (CAUTI)
- Remove or replace catheter if possible before starting antibiotics
- Treat symptomatic CAUTI only (not asymptomatic bacteriuria)
- Duration: 7 days (if prompt response) to 10–14 days
Recurrent Cystitis (≥2 episodes in 6 months or ≥3 in 1 year)
- Confirm each episode with culture
- Non-antibiotic strategies: Increased fluid intake, post-coital voiding, vaginal estrogen (postmenopausal women), D-mannose
- Antibiotic prophylaxis options:
- Continuous low-dose: Nitrofurantoin 50–100 mg nightly or TMP-SMX 40/200 mg nightly
- Post-coital: Single dose TMP-SMX or nitrofurantoin
- Patient-initiated self-treatment
6. Symptomatic Relief
- Phenazopyridine (urinary analgesic): 200 mg TID × 1–2 days for dysuria relief; not an antibiotic — turns urine orange
- Adequate hydration
7. Antibiotic Stewardship Notes
- Always base definitive therapy on urine culture and sensitivity
- Avoid fluoroquinolones as first-line for uncomplicated cystitis (per IDSA 2011 guidelines and subsequent updates) due to adverse effect profile and resistance selection pressure
- Check local antibiogram for TMP-SMX resistance rates before use
- Asymptomatic bacteriuria should not be treated (except in pregnancy or pre-urological procedures)
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