Key Points
ÎÎPreferred antibiotics for acute cystitis are nitrofurantoin, or
trimethoprim-sulfamethoxazole (TMP-SMX) if local resistance
rates are < 20%.
ÎÎIn patients suspected of pyelonephritis, a urine culture and
susceptibility testing should always be performed.
ÎÎPreferred antibiotics for outpatient pyelonephritis are a
fluoroquinolone or TMP-SMX. Consider an initial single-dose IV
ceftriaxone or an aminoglycoside if community resistance is
> 10% or, for TMP-SMX, if susceptibility unknown.
ÎÎWomen with pyelonephritis requiring hospitalization should
be initially treated with an IV antimicrobial regimen such as a
fluoroquinolone, an aminoglycoside with or without ampicillin,
an extended-spectrum cephalosporin or extended-spectrum
penicillin with or without an aminoglycoside, or a carbapenem.
Selecting a Treatment Regimen
Acute Uncomplicated Cystitis
ÎNitrofurantoin monohydrate/macrocrystals 100 mg bid for 5 days
Î
is an appropriate choice for therapy due to minimal resistance and
propensity for collateral damage; efficacy is comparable to 3 days
of TMP-SMX (A-I).
ÎÎTMP-SMX DS bid for 3 days is an appropriate choice for
therapy, given its efficacy as assessed in numerous clinical
trials, if local resistance rates of uropathogens causing acute
uncomplicated cystitis do not exceed 20% or if the infecting
strain is known to be susceptible (A-I).
>> Notes: The threshold of 20% as the resistance prevalence at which the agent is no
longer recommended for empiric treatment of acute cystitis is based on expert opinion
derived from clinical, in vitro, and mathematical modeling studies (B-III).
>> In some countries and regions, trimethoprim 100 mg bid for 3 days is the preferred
agent and is considered equivalent to TMP-SMX based on data presented in the
original guideline (A-III).
>> Data are insufficient to make a recommendation for other cystitis antimicrobials
as to what resistance prevalence should be used to preclude their use for empiric
treatment of acute cystitis.