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

Antibiotics are used to control bacterial infection. It is vital that one finish an entire course of prescribed antibiotics. Commonly used antibiotics include:

• Nitrofurantoin
• Trimethoprim-sulfamethoxazole
• Amoxicillin
• Cephalosporins
• Ciprofloxacin or levofloxacin

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. The choice of antibiotic should preferably be guided by the result of urine culture. Chronic or recurrent UTI should be treated thoroughly because of the chance of kidney infection (pyelonephritis). Antibiotics control the bacterial infection. They may be required for long periods of time. Prophylactic low-dose antibiotics are sometimes recommended after acute symptoms have subsided. Pyridium may be used to reduce the burning and urgency associated with cystitis. In addition, common substances that increase acid in the urine, such as ascorbic acid or cranberry juice, may be recommended to decrease the concentration of bacteria in the urine. Follow-up may include urine cultures to ensure that bacteria are no longer present in the bladder.

Shown below is a table summarizing the preferred and alternative empiric treatment for cystitis.

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.

_{† Acute uncomplicated cystitis: Premenopausal, nonpregnant women with no known urological abnormalities or comorbidities,postmenopausal women or well-controlled diabetes female patient. ‡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.

• 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 multi-drug resistant organisms, so they are used as alternative to the first line drugs in case of allergy, availability or tolerance.