Cystitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yazan Daaboul, M.D.

Overview

Antimicrobial therapy is indicated in cystitis. The treatment of cystitis depends on the disease course (acute uncomplicated vs. complicated) and the rates of resistance in the community. Due to the risk of the infection spreading to the kidneys (complicated UTI) and the high complication rate in diabetics and the elderly population, prompt treatment is almost always recommended.

Principles of Medical Therapy

• The choice of therapy depends on whether the patient has uncomplicated vs. complicated cystitis, known patient allergies, and regional resistance patterns.
• Cystitis among men is always considered complicated cystitis and should be managed accordingly.
• Symptomatic women with NO history of urinary tract infection or a lab-confirmed infection are recommended to undergo testing for urinary tract infection by urinalysis or dipstick testing for the detection of pyuria.
• Symptomatic women who have had frequent recurrences in the past and prior confirmation of urinary tract infections may be treated empirically.
• For women with first-time cystitis, a urine culture is not required prior to administration of empiric therapy.

Acute Uncomplicated Cystitis

• Patients with acute uncomplicated cystitis may be treated using a single antimicrobial therapy using either a single dose or a 3-day regimen. The following list of antimicrobial agents may be administered:
• Empiric Therapy:

• Preferred regimen (1): Fosfomycin tromethamine 3 g PO single dose
• Preferred regimen (2): Nitrofurantoin monohydrate/macrocrystals 100 mg PO bid for 5 days
• Preferred regimen (3): Trimethoprim-Sulfamethoxazole 160/800 mg PO double-strength tablet bid for 3 days
• Preferred regimen (4): Trimethoprim 100 mg PO bid for 3 days
• Alternative regimen (1): Ciprofloxacin 250 mg PO bid for 3 days
• Alternative regimen (2): Levofloxacin 250 mg PO qd for 3 days
• Alternative regimen (3): Norfloxacin 400 mg PO bid for 3 days
• Alternative regimen (4): Gatifloxacin 200 mg PO qd for 3 days
• Note (1): Avoid Nitrofurantoin and Fosfomycin is pyelonephritis is suspected
• Note (2): Avoid Trimethoprim-based regimens if resistance regional prevalence exceeds 20% or if patient had a prior UTI within the past 3 months
• Note (3): β-lactam-based regimens are less effective than other available agents and are only indicated when other agents cannot be used.

Complicated Cystitis

• Patients with complicated cystitis generally require a longer duration of therapy compared with patients with uncomplicated cystitis.
• Patients who meet at least one of the following criteria are considered to have complicated cystitis:

• Male gender
• Pregnant women
• Children with metabolic diseases
• Children with genitourinary abnormalities
• Patients suspected to be at high risk of developing complications or treatment failure, including:

• Patients with ureteric stents
• Patients with urinary stone
• Patients with neurogenic bladder
• Immunocompromised patients
• Renal failure patients
• Renal transplant patients

• Special attention to the choice of antimicrobial therapy is required when administering antimicrobial agents to children and pregnant/lactating women. In pregnancy, Nitrofurantoin, Sulfonamide, Trimethoprim, and fluoroquinolones should be avoided.
• The duration of therapy for the management of cases of complicated cystitis is not well established. The majority of clinical trials evaluated the efficacy of antimicrobial agents over 7-14 days (range: 5-20 days).
• The general consensus is to treat complicated cases of complicated cystitis for 7 days.
• Long-term therapy among high-risk patients is not established and is often tailored on an individual basis.

Recurrent Cystitis

• Patients with recurrent cystitis may require prolonged prophylactic antimicrobial therapy for 6-12 months.
• The same antimicrobial agents that are indicated for uncomplicated cystitis are also indicated for recurrent cystitis.
• Patients with recurrent cystitis should be re-evaluated at the time of completion of therapy.
• Patients who develop recurrent UTI following sexual activity may benefit from prophylactic antimicrobial therapy. To view the list of regimens indicated for the primary prevention of cystitis, click here.