Bladder infection (bacterial cystitis): Treatment

Review literature: (Fihn, 2003) (Krieger, 2003).

Treatment of Acute Bladder Infection

Treatment of Uncomplicated Bladder Infection in Women

Symptomatic treatment:

Plenty of drinking, warm sitz baths, anticholinergics.

Penicillins:

Pivampicillin 400 mg 1-0-1, amoxicillin with clavulanic acid 875 mg 1-0-1 for 3 days.

Cephalosporins:

Cefpodoxime 100 mg 1-0-1 for 3 days. Alternatives: cefuroxim, cefdinir or cefaclor.

Nitrofurantoin:

Nitrofurantoin acts as a surface disinfectant, sufficient effective in uncomplicated cystitis. Dosage 100 mg 1-1-1 for 3–7 days.

Fosfomycin:

A single dose of 3 g Fosfomycin leads to the urinary excretion of the drug in the urine over 2–4 days with a sufficient therapeutic concentration.

Co-trimoxazole (TMP-SMX):

Co-trimoxazole 960 mg consists of 160 mg trimethoprim and 800 mg sulfamethoxazol. The dosage for bladder infection is 1-0-1 p.o. for three days. Single dosage (3 tablets at once) is possible, but somewhat less effective. High resistance rates of up to 30%.

Fluoroquinolones:

Ofloxacin 100–200 mg 1-0-1, 1-0-1 norfloxacin 400–800 mg 1-0-0, Ciprofloxacin 250–500 mg 1-0-1, levofloxacin 250–500 mg 1-0-0 for three days. The single dosage of fluoroquinolones is possible, but somewhat less effective: a single dose of Ciprofloxacin 500 mg, levofloxacin 500 mg, ofloxacin 200 mg. The resistance rate to fluoroquinolones develops unfavorable, in some regions up to 30%.

Treatment of Uncomplicated Cystitis in Men or Complicated Cystitis in Women

A urine culture should be started before initiation of treatment with co-trimoxazole, fluoroquinolones or oral cephalosporin for 7 days. After receiving the results from the urine culture, it might be necessary to adjust the choice of the antibiotic.

Treatment of Bladder Infection in Pregnancy

Possible and save antibiotics are amoxicillin 250 mg 1-1-1 p.o. or an oral cephalosporin such as Cefpodoxime 100–200 mg 1-0-1 or cefuroxim 500 mg 1-0-1 for three days. Bacteriuria without symptoms should be treated during pregnancy, since the risk for a pyelonephritis amounts to 30% [see section urinary tract infections in pregnancy].

Treatment of Bladder Infection in Children

Oral therapy for 2–4 days is usually sufficient; other studies support a treatment for 7–10 days. The following antibiotics are suitable for children: co-trimoxazole, oral cephalosporins and amoxicillin. The dosage is depending on body weight.

Treatment of Fungal Bladder Infection (Candida Cystitis)

Asymptomatic funguria should not be treated. In clinical significant bladder infection, treatment options are fluconazole 200 mg 1-0-0 for 14 days, bladder rinsing with amphotericin B or amphotericin B i.v. in a single dose.

Prevention (Prophylaxis) of Recurrent Bladder Infection

Sex and Bladder Infections

Sexual intercourse is a strong risk factor for bladder infection (honeymoon cystitis). Following measures reduce the risk of bladder infection: micturition after sexual intercourse, high diuresis, no diaphragm or spermicide for contraception, avoidance of anal intercourse.

If above mentioned prevention measures are not effective, a single dose of antibiotics (fluoroquinolone, co-trimoxazole or nitrofurantoin) after sex reduces the incidence of bladder infection.

Cranberry Juice in Recurrent Cystitis

Regular consumption of cranberry juice or concentrate (twice daily) reduces the incidence of urinary tract infections (relative risk reduction of 0.6). Proposed mechanisms are the interaction of cranberry juice with the adherence abilities of the bacteria with the urothelium and bacteriostatic properties.

Recurrent Bladder Infection in Postmenopausal Women

Estrogen deficiency in postmenopausal women is a risk factor for recurrent urinary tract infections. Estrogen replacement therapy leads to a reduction of urinary tract infections. Local estrogen replacement therapy (vaginal cream or vaginal estrogen implants) are more successful and less harmful than oral hormone replacement therapy.

Vaccination against Recurrent Bladder Infection

Oral vaccination with inactivated but immunogenic E. coli strains (e.g. Uro-Vaxom) shows a protective effect.

Low-dose Long-Term Antibiotic Prophylaxis

A low-dose long-term antibiotic prophylaxis is possible with trimethoprim, cotrimoxazole, cephalexin, nitrofurantoin or fluoroquinolones. In studies (prophylaxis period of up to five years), a significant reduction of symptomatic urinary tract infections without significant increase of drug-resistant urinary tract infections could be achieved. After completion of the prophylaxis, the same frequency of urinary tract infections as before can be observed.

Alternatively, on-demand antibiotic therapy should be started by the patient with the onset of symptoms.

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References

Fihn 2003 FIHN, S. D.:

Clinical practice. Acute uncomplicated urinary tract infection in women.
In: N Engl J Med
349 (2003), Nr. 3, S. 259–66

Krieger 2003 KRIEGER, J. N.:

Urinary tract infections: what’s new?
In: J Urol
168 (2003), S. 2351–58.