Clinical Features And Diagnosis Top
Typical clinical features of uncomplicated cystitis include dysuria, frequency, and suprapubic pain, sometimes also urgency/incontinence and hematuria (in ~40% of patients), as well as suprapubic tenderness. Additionally, leukocyturia and bacteriuria >105 colony-forming units (CFUs)/mL (in some patients 102-104 CFU/mL) are seen. Untreated uncomplicated cystitis may last from a few to over 10 days. Urine cultures are usually performed and imaging studies can be considered if the symptoms persist despite treatment or recur within 1 to 4 weeks.
1. First-line agents:
1) Oral nitrofurantoin 100 mg bid for 3 to 5 days (preferred agent due to low resistance rates and similar efficacy as sulfamethoxazole/trimethoprim).Evidence 1Strong recommendation (downsides clearly outweigh benefits; right action for all or almost all patients). High Quality of Evidence (high confidence that we know true effects of the intervention). Gupta K, Hooton TM, Roberts PL, Stamm WE. Short-course nitrofurantoin for the treatment of acute uncomplicated cystitis in women. Arch Intern Med. 2007 Nov 12;167(20):2207-12. PubMed PMID: 17998493.
2) Other options include sulfamethoxazole/trimethoprim 960 mg bid for 3 days or trimethoprim 100 mg bid for 3 days, fosfomycin 3 g in a single dose (in particular if an extended-spectrum beta-lactamase [ESBL]–producing strain is suspected).
3) In areas where >20% of Escherichia coli strains are resistant to sulfamethoxazole/trimethoprim and resistance rates to fluoroquinolones are <20%, consider a 3-day course of ciprofloxacin 250 to 500 mg bid, norfloxacin 400 mg bid, or ofloxacin 200 mg bid.
2. Second-line agents: Oral amoxicillin + clavulanic acid 625 mg bid for 3 to 7 days, cephalexin (INN cefalexin) 500 mg qid for 3 to 7 days, amoxicillin 500 mg tid for 7 to 10 days.
3. Ibuprofen is inferior to antibiotic treatment, but two-thirds of women with uncomplicated cystitis recover without antibiotics. Therefore, ibuprofen can be considered if patients would prefer to avoid exposure to antibiotics.
4. Follow-up: In female patients with no symptoms persisting after treatment, no follow-up urine testing is indicated.