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Uncomplicated Cystitis

UTI

Source: IDMP View on spectrum chart →
Patient + scenario modifiers
Patient
Clinical scenario / source

Annotations only — chart still shows the full chemistry of each drug.

1. Clinical Syndrome

Acute lower UTI in a non-pregnant, premenopausal woman without anatomic / functional urinary tract abnormalities. Symptoms: dysuria, frequency, urgency, suprapubic pain. Pyuria + bacteriuria on UA.

Excludes: male anatomy, pregnancy, indwelling catheter, recurrent UTI, recent urologic instrumentation, immunocompromise, signs of pyelo (flank pain, fever, costovertebral tenderness).

2. Pathogens

Consider the patient: Pregnancy (changes drug choice), recent antibiotics (resistance risk), prior multidrug-resistant UTI, age (post-menopausal: atrophy contributes), DM, immunocompromise.

Consider the case: Recurrence (≥2 in 6 mo or ≥3 in 12 mo → workup), local antibiogram resistance for E. coli.

Common

Less common

3. Empiric Therapy

TierFirst choiceAlternativesDurationComments
Outpatient
  • Nitrofurantoin 100 mg · PO BID · PO · 5 days

    Avoid if CrCl <30. Macrobid (monohydrate) preferred — better tolerated than macrocrystals.

  • TMP-SMX DS 1 tab (160/800 mg) · PO BID · PO · 3 days

    Avoid if local E. coli resistance >20% or recent abx use.

  • Fosfomycin 3 g · single dose · PO · 1 dose

    Single-dose convenience. β-lactam alternatives (amox-clav, cephalexin) less effective — reserve for cases where first-line isn't tolerated.

3–5 daysNitrofurantoin and fosfomycin remain reliably active against most E. coli including ESBL strains. Avoid fluoroquinolones in uncomplicated cystitis (FDA boxed warning + collateral damage).

4. Directed Therapy

Once urine culture back:

  • E. coli pan-susceptible: continue first-line
  • ESBL E. coli: nitrofurantoin (cystitis only) or fosfomycin remain options. For pyelo or upper UTI: ertapenem / meropenem.
  • Enterococcus: ampicillin or amoxicillin if susceptible.

No follow-up culture needed if symptoms resolve.

5. Monitoring

Resolution: symptoms improve within 48 h. If not, reassess for resistance / pyelonephritis / complicated UTI.

Toxicity: nitrofurantoin — pulmonary fibrosis (chronic use), hepatitis. TMP-SMX — hyperkalemia (esp. with ACE inhibitors), rash, marrow suppression.

Pearls

Don't treat asymptomatic bacteriuria in non-pregnant adults — even with diabetes or catheters. Exception: pre-urologic procedure with mucosal trauma.

References