Key Points
ÎPreferred antibiotics for acute cystitis are nitrofurantoin, or trimethoprim-sulfamethoxazole (TMP-SMX) if local resistance rates are < 20%.
ÎIn patients suspected of pyelonephritis, a urine culture and susceptibility testing should always be performed.
ÎPreferred 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.
ÎWomen 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 for 5 days
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).
ÎTMP-SMX DS 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.
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