Cystitis medical therapy

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

Overview

Because of the risk of the infection spreading to the kidneys (complicated UTI) and due to the high complication rate in the elderly population and in diabetics, prompt treatment is almost always recommended.

Medical Therapy

The decision to use antimicrobials should be case by case, in other word it should depend on the patients specifics like allergy and compliance history, availability and cost of treatment and resistant rates at the local community.

Uncomplicated cyctitis

Acute uncomplicated cystitis definition includes Premenopausal, nonpregnant women with no known urological abnormalities or comorbidities,postmenopausal women or well-controlled diabetes female patients.

Acute Bacterial Uncomplicated Cystitis† Preferred Regimen ▸ Nitrofurantoin 100 mg po q12h×5 days OR ▸ TMP-SMX‡ 1 DS tab po q12h×3 days OR ▸Fosfomycin 3 gm single dose OR ▸Pivmecillinam♦ 400 mg bid×5 days Alternative Regimen ▸ Fluoroquinolones for 3 days Ofloxacin 200–400 mg po bid. Ciprofloxacin 250 mg bid po or Cipro XR 500 mg q24h Levofloxacin 250–750 mg po q24 OR ▸β-lactam agents for 3-7 days Amoxicillin-clavulanate 500/125 mg po tid or 875/125 mg po bid Cefdinir 300 mg po q12h or 600 mg po q24 Cefaclor 250-500 mg po q8h Cefpodoxime-proxetil 100-200 mg po q12h Others(Cephalexin250-500 mg po q6h ) not studied well but effective.

_{‡Avoid if resistance prevalence is known to exceed 20% or if used for UTI in previous 3 months.} ♦_{Pivmecillinam is available in some European countries, not licensed in US.}

• Being the most common cause of cystitis(75-90%), E.Coli susceptibility should be considered to choose the appropriate empirical antimicrobial.Other organisms like Proteus mirabilis, Klebsiella pneumoniae and Staphylococcus saprophyticus are far less common.

• Nitrofurantoin, fosfomycin and mecillinam are prefered as first line treatment because have less resistance among other antibacterials with similar efficacy.

• TMP-SMX is preferred to use in areas where the resistance rates are less than 20%.

• Nitrofurantoin, fosfomycin and mecillinam shouldn't be used when pyelonephritis is suspected, because they have weak penetration to the renal tissue.
• Use of broad-spectrum antimicrobials resulted multidrug resistant organisms,so they are used as alternative to the first line drugs in case of allergy, unavailability or intolerance.
• Beta-lactams have less efficacy than fluoroquinolones.
• Post-therapy urine culture is recommended only for pregnant women, multiple early recurrences with the same strain of bacteria and for persistent hematuria.

Complicated cyctitis

All men considered as complicated infection, others include pregnant women and children with metabolic or anatomical abnoramlities, as a general rule all patients with risk of serious complications and/or failure of treatment(stones, obstruction, immunocompromised patients, neurogenic bladder, renal failure,transplant patients) considered as complicated infections

Complicated cyctitis Regimen ▸ Fluoroquinolones for ≥7 days Ofloxacin 200–400 mg po bid. Ciprofloxacin 250 mg bid po or Cipro XR 500 mg q24h Levofloxacin 250–750 mg po q24.

Recurrent cystitis

Recurrent cystitis suggests antimicrobial resistance.

• Recurrence or persistence of urinary symptoms within one or two weeks of treatment of uncomplicated cystitis, the treatment should be initiated after urine culture with broad-spectrum fluoroquinolones.
• Recurrence at least one month after successful treatment is treated with first line, short course(7 days) regimen.
• Recurrence within 6 month of successful treatment should be treated with another first line agent than the one used first time.
• In postmenopausal women, it's recommended to evaluate correctable factors like cystocele, incontinence and residual urine volume ≥50 ml.