Treating Uncomplicated Cystitis

Kiran Panesar, BPharmS (Hons), MRPharmS, RPh, CPh

Disclosures

US Pharmacist. 2013;38(8):34-37. 

In This Article

Treatment

Cystitis very rarely develops into a more severe form even when untreated. The main goal of treatment is to ameliorate the symptoms that the patient is experiencing.[2]

Phenazopyridine hydrochloride is a urinary analgesic that is widely available in many OTC preparations (Table 1).[13] It is an azo dye that exerts a local anesthetic effect on the mucosa of the urinary tract, providing relief from dysuria and bladder spasms. The recommended dosage is 100 to 200 mg twice daily for 2 days. Patients should be informed that the medication turns urine and tears dark orange, stains contact lenses, and interferes with urinalysis.[13]

A number of antibiotic regimens, both conventional (7–14 days) and short term (1–3 days) are presently available to treat the bacterial infection.[14] Updated guidelines released by the Infectious Diseases Society of America (IDSA) in 2010 can assist health care professionals in the management of women with uncomplicated UTIs.[15] The recommended dosages are listed in Table 2.[2,15]

Nitrofurantoin

Nitrofurantoin is listed as an appropriate choice of therapy since it has similar efficacy to trimethoprim-sulfamethoxazole (TMP-SMX), minimal resistance, and minimal collateral damage.[15] It has been used for over 50 years and is still one of the most active drugs against E coli.[16]

The most common adverse effects of nitrofurantoin involve the gastrointestinal (GI) tract and are normally dose related.[17] These effects, including nausea, vomiting, anorexia, abdominal pain, flatulence, and diarrhea, tend to be less common when the nitrofurantoin is administered in its macrocrystalline form. Other side effects include headache, drowsiness, vertigo, dizziness, nystagmus, and intracranial hypertension. In rare cases, severe peripheral polyneuropathy may develop, and patients may experience hypersensitivity reactions extending up to an asthma attack. Patients should be advised that nitrofurantoin may cause a false-positive reaction in urine tests for glucose using copper reduction methods, and may discolor urine brown.[17]

Nitrofurantoin should be avoided in patients with renal failure or pyelonephritis; in patients who are sensitive to nitrofurans; and in those with glucose-6-phosphate dehydrogenase (G6PD) deficiency.[2,17] While nitrofurantoin is safe in pregnancy, it can cause hemolytic anemia due to glutathione instability in the immature erythrocytes of the fetus or newborn. For this is reason, it is best avoided near term or during labor.[18]

Concomitantly administered quinolones antagonize the action of nitrofurantoin, while probenecid and sulfinpyrazone reduce its excretion.[17]

TMP-SMX

TMP-SMX is considered first-line therapy, as it is effective despite increasing resistance and has fewer ecologic adverse effects than seen with fluoroquinolones.[2,15] This means that TMP-SMX has a lower likelihood of inducing resistance to antimicrobials than fluoroquinolones. A randomized, comparative trial showed that a 3-day course of TMP-SMX was more effective and less expensive than a course of nitrofurantoin, cefadroxil, or amoxicillin of the same duration at treating uncomplicated cystitis in women.[19]

TMP-SMX is inexpensive and relatively well tolerated, with the most common adverse effects being those of the GI tract such as nausea, vomiting, and anorexia, as well as skin reactions including rash, urticaria, and photosensitivity. Rarely, hematologic complications have led to death, particularly in elderly patients.[2,17] If a rash appears, treatment should be discontinued immediately due to the risk of severe allergic reactions such as Stevens-Johnson syndrome with SMX.[17]

Patients should be advised to drink adequate fluids to prevent the risk of crystalluria with SMX.[17] For the same reasons, the concomitant administration of any compound that renders the urine acidic should be avoided.[17]

Caution should be used in patients with renal or hepatic failure, and in severe cases TMP-SMX should be avoided altogether due to the SMX content. Likewise, TMP should be avoided in patients with hematologic disorders and in those with a folate deficiency. While TMP-SMX is widely used in pregnancy, recent studies suggest it might not be safe, particularly in the first trimester.[20] Fluoroquinolones or beta-lactams may be indicated as suitable alternatives in patients who cannot tolerate TMP-SMX.[2]

Fluoroquinolones

The fluoroquinolones ofloxacin, ciprofloxacin, and levofloxacin should only be used as first-line therapy in communities with high rates of TMP-SMX resistance (≥10%) to E coli since these agents have other important indications.[2] Fluoroquinolones have been shown to have similar effects to TMP-SMX when given for 3 days to treat uncomplicated UTIs in women.[14]

This group of drugs has a propensity for adverse effects including nausea, vomiting, diarrhea, headache, drowsiness, insomnia, rash, and pruritus. In rare cases, patients may experience pseudomembranous colitis.[17] Other side effects reported include hematologic disorders, renal effects, crystalluria, and cardiovascular effects such as tachycardia. Patients should be advised to maintain an adequate fluid intake to reduce the risk of crystalluria and to avoid strong sunlight or sunlamps.[17]

Fluoroquinolones should be used with caution in patients with epilepsy or other central nervous system (CNS) disorders, renal or hepatic impairment, or G6PD deficiency.[17] They should not be given to children, teenagers, and pregnant or lactating mothers because of the risk of tendon damage.[17,21] The absorption of fluoroquinolones is reduced with the concomitant administration of aluminum, magnesium, or iron-containing products.[17]

Beta-Lactams

Beta-lactams are generally not recommended because of limited efficacy in treating UTIs, as many strains of E coli have become resistant to ampicillin.[2,3] However, these agents generally have fewer ecologic adverse effects than are seen with parenteral broad-spectrum cephalosporins.[2] The most common adverse effects associated with beta-lactams are hypersensitivity reactions, particularly rashes and urticaria, as well as GI disturbances.

Beta-lactams should not be prescribed to patients with a known allergy to penicillins or cephalosporins. Unlike some other antimicrobials available to treat UTIs, beta-lactams are considered safe to use in pregnancy.[8,22,23]

Fosfomycin

While fosfomycin has lower resistance and a lower propensity for ecologic damage, it also has inferior efficacy when compared to TMP-SMX or fluoroquinolones.[15] Its range of possible adverse effects includes nausea, headache, diarrhea, vaginitis, skin rashes, and visual disturbances. It should be avoided if pyelonephritis is suspected due to the risk of hepatic side effects. Fosfomycin is considered safe in pregnancy, but its use in pregnant women is limited.[22] The fosfomycin powder contained in the sachet must not be taken dry. It must be mixed with water before ingesting, and may be taken with or without food.

Other Treatment Considerations

In addition to the efficacy of the regimen, it is important to take into consideration patient allergies, compliance history, local practice patterns, local resistance trends, availability, and cost to the patient.[2] As many uropathogenic strains develop resistance to antimicrobials, including TMP-SMX, the effective management of UTIs including cystitis is becoming complicated.[3]

Short-course therapies have been shown to offer improved compliance, a lower risk of adverse reactions, and lower cost compared to conventional therapies.[14] A randomized trial found that short-course ciprofloxacin therapy of 3 to 5 days had an outcome similar to that of conventional ciprofloxacin or norfloxacin therapy of 7 days.[14] Within the short-course therapies, the single-dose regimens have shown lower cure rates and a higher rate of recurrence than the 3-day regimens.[14] In older women, however, there is some evidence for a 7-day antibiotic regimen, although a Cochrane review showed no additional benefit of increased duration of therapy.[24] Men generally require a longer duration of therapy than women because of poor tissue penetration as well as the presence of a larger number of complicating factors.[2,25]

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