Cystitis medical therapy

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Steven C. Campbell, M.D., Ph.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

• 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 lower UTI, a urine culture is not required prior to administration of empiric therapy.
• The choice of therapy depends on whether the patient has uncomplicated vs. complicated cystitis, known patient allergies, and regional resistance patterns as shown in the algorithm below:

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
• Preferred regimen (8): 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 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 urinary stone
• Patients with neurogenic bladder
• Immunocompromised patients
• Renal failure patients
• Transplant patients

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.

Cystitis in Pregnancy

• Urine culture is obtained after completion of antimicrobials regimen.
• Nitrofurantoin and Sulfonamides (category B) are not preferred before delivery. Nitrofurantoin should be avoided when G6PD deficiency is suspected with the fetus due to the risk of hemolytic anemia. Sulfonamides have been associated with increased unbound bilirubin levels in fetal blood and kernicterus.
• Trimethoprim (category C) is a folic acid antagonist, therefore it is not used in the first trimester to avoid the risk of possible birth defects.

==Empiric Therapy for Acute Cystitis== Adapted from Clin Infect Dis. 2011;52(5):e103-20.

Acute Bacterial Uncomplicated Cystitis Preferred Regimen ▸ Nitrofurantoin 100 mg PO q12h × 5 days OR ▸ TMP 100 mg PO q12h ×3 days OR ▸ Fosfomycin 3 gm PO single dose OR If resistence<20% or if used for UTI >3 months ▸ TMP-SMX ‡ 1 DS tab PO q12h × 3 days OR Not FDA approved but used in some European countries ▸ Pivmecillinam 400 mg PO q12h 3-7 days Alternative Regimen ▸ Fluoroquinolones for 3 days ▸Ofloxacin 200–400 mg PO bid OR ▸Ciprofloxacin 250 mg bid PO or Cipro XR 500 mg q24h OR ▸Levofloxacin 250–750 mg PO q24 OR ▸ β-lactam agents for 3-7 days ▸Amoxicillin-clavulanate 500/125 mg PO q8h or 875/125 mg PO q8h OR ▸Cefdinir 300 mg PO q12h or 600 mg PO q24 OR Cefaclor 250-500 mg PO q8h OR ▸Cefpodoxime proxetil 100-200 mg PO q12h OR Cephalexin250-500 mg PO q6h not studied well but effective.

Complicated/Catheter Associated Cystitis Preferred Regimen Mild Infection ▸ Levofloxacin 750 mg PO q24 × 5 days Delayed Response ▸ Levofloxacin 750 mg PO q24 × 10-14 days After Catheter Removal ▸ Levofloxacin 750 mg PO q24 × 3 days Acute Cystitis in Pregnancy Preferred Regimen ▸Nitrofurantoin 100 mg PO q12h × 3-5 days OR ▸ Fosfomycin 3 g PO single dose OR ▸Amoxicillin-clavulanate 500/125 mg PO q12h × 3-5 days OR ▸ Amoxicillin 500 mg PO q12h × 3-5 days OR ▸Cephalexin 500 mg PO q12h × 3-5 days OR ▸ TMP-SMX DS 1 tab PO q12h × 3-5 days avoid in first trimester(TMP) and third trimester (SMX).