Cystitis Empiric Therapy

Uncomplicated cystitis occurs in patients who have a normal, unobstructed genitourinary tract, who have no history of recent instrumentation, and whose symptoms are confined to the lower urinary tract. Uncomplicated cystitis usually affects young and sexually active women. Patients usually present with dysuria, hematuria, increased urinary frequency, urinary urgency, lower abdominal pain, and/or fever.[1, 2, 3, 4]

Primary regimens

Primary regimens include:

• Nitrofurantoin monohydrate/macrocrystals (Macrobid) 100 mg PO BID for 5 days or

• Trimethoprim/sulfamethoxazole 160 mg/800 mg (Bactrim DS, Septra DS) 1 tablet PO BID for 3 days (use when bacterial resistance is < 20% and patient has no allergy) or

Alternative therapy

Alternative therapies include:

• Ciprofloxacin (Cipro) 250 mg PO BID for 3 days or

• Ciprofloxacin extended-release (Cipro XR) 500 mg PO BID for 3 days or

• Levofloxacin (Levaquin) 250 mg PO BID for 3 days

• Amoxicillin-clavulanate (Augmentin) 875 mg/125 mg PO BID for 7 days or

• Amoxicillin-clavulanate (Augmentin) 500 mg/125 mg PO TID for 7 days or

• Cefdinir 300 mg PO BID for 7 days or

• Cefaclor 500 mg PO TID for 7 days or

• Cefpodoxime-proxetil 100 mg PO BID 7 days

• Fosfomycin (Monurol) 3 g PO with 3-4 oz of water X 1 dose

Short-course therapy may not be sufficient in women with a previous history of urinary tract infection (UTI) caused by resistant organisms or UTI with symptoms lasting more than 7 days. In these cases, a longer course of antibiotic therapy (7-10 days) is required.[1]

Complicated cystitis is associated with an underlying condition that increases the risk of therapy failure. Some underlying conditions include diabetes mellitus, symptoms for 7 days or more before seeking care, renal failure, functional or anatomic abnormality of the urinary tract, renal transplantation, an indwelling catheter stent, or immunosuppression.[1, 2, 4, 5]

Preferred therapy is as follows:

• Ciprofloxacin (Cipro) 500 mg PO BID for 7-14 days or

• Ciprofloxacin extended-release (Cipro XR) 1 g PO daily for 7-14 days or

• Levofloxacin (Levaquin) 750 mg PO daily for 7-14 days or

• Trimethoprim/sulfamethoxazole 160 mg/800 mg (Bactrim DS, Septra DS) 1 tablet PO BID for 7- 14 days (use when bacterial resistance is < 20% and patient has no allergy)

• Nitrofurantoin monohydrate/macrocrystals (Macrobid) 100 mg PO BID for 7- 14 days or

• Fosfomycin (Monurol) 3 g PO with 3-4 oz of water every 3 days for 2 doses

Shorter courses of antibiotic therapy are preferred in pregnant patients. Fluoroquinolones are contraindicated during pregnancy and should not be used. Nitrofurantoin is contraindicated in pregnant patients at term, during labor, and during delivery.[1, 2, 6]

Preferred therapy is as follows:

• Nitrofurantoin monohydrate/macrocrystals (Macrobid) 100 mg PO BID for 5-7 days or

• Amoxicillin-clavulanate (Augmentin) 500 mg/125 mg PO BID for 5-7 days or

• Cephalexin (Keflex) 500 mg PO QID for 3-5 days or

• Cefpodoxime 100 mg BID for 5-7 days or

• Fosfomycin (Monurol) 3 g PO in a single dose with 3-4 oz of water

By definition, any case of cystitis in a male is considered complicated. Men with cystitis who do not have signs or symptoms of prostatitis can be treated with the following preferred regimens:[1, 2]

Primary regimens:

•  Trimethoprim/sulfamethoxazole 160 mg/800 mg (Bactrim DS, Septra DS) 1 tablet PO BID for 7 days (use when bacterial resistance is < 20% and patient has no allergy)

• Ciprofloxacin (Cipro) 500 mg PO BID for 7 days or

• Ciprofloxacin extended-release (Cipro XR) 1000 mg PO once daily for 7 days or

• Levofloxacin 750 mg PO once daily for 7 days or

• Nitrofurantoin monohydrate/macrocrystals (Macrobid) 100 mg PO BID for 7 days or

Alternative regimens:

• Amoxicillin-clavulanate (Augmentin) 875/125 mg PO BID for 7 days or

• Cephalexin (Keflex) 500 mg PO QID for for 7 days or

• Cefdinir 300 mg po BID for 7 days or

• Cefpodoxime 100 mg BID for 7 days or

• Fosfomycin (Monurol) 3 g PO in a single dose with 3-4 oz of water