Dr. med. Dirk Manski

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Treatment of Bladder infection (Bacterial Cystitis)

Guidelines: (S3 German Guideline), (EAU Guidelines).

Treatment of Bladder Infection without Antibiotics

Management of asymptomatic bacteriuria:

For most patients, in the absence of symptoms (dysuria, fever, pain), screening (urine culture without symptoms) is not indicated, and treating asymptomatic bacteriuria with antibiotic therapy is expressly not recommended.

Symptomatic therapy of mild cystitis:

Mild bacterial cystitis can be managed with a wait-and-see behavior and symptomatic therapy without antibiotics. Increased fluid intake, warm sitz baths, analgesics and anticholinergics are prescribed until the culture results are ready. If there is insufficient improvement with symptomatic therapy, proceed with antibiotic therapy (see below). After one week, the spontaneous healing rate of acute uncomplicated cystitis is 30–50%.

Antibiotic therapy of uncomplicated cystitis:

The following table provides an overview of antimicrobial resistance regarding common antibiotics prescribed for UTIs. Antibiotics of first choice for uncomplicated cystitis are fosfomycin, nitrofurantoin, nitroxoline, pivmecillinam, trimethoprim, or cotrimoxazole. They are sufficiently effective, have a favorable side effect profile, and have a low impact on resistance formation and microbiome.

Antibiotic options for treating acute cystitis, sorted by resistance to E. coli from several studies (German Guideline UTI). (*) Amoxicillin/clavulanic acid.
Antibiotikum Sensibel Resistent
Pivmecillinam 98% 1%
Fosfomycin 96% 1%
Cefuroxime 89% 2%
Amox./Clav. (*) 87% 3%
Nitrofurantoin 86% 5%
Ciprofloxacin 92% 7%
Nalidixinsäure 91% 9%
Cotrimoxazole 74% 26%
Ampicillin 57% 38%


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.


Nitrofurantoin is excreted via the urine and is sufficiently effective to treat uncomplicated cystitis. Dosage 100 mg 1-0-1 for 5–10 days.


Nitroxoline is excreted via the urine and is sufficiently effective to treat uncomplicated cystitis. Dosage 250 mg 1-1-1 for 5–10 days.


Pivampicillin 400 mg 1-1-1, or amoxicillin with clavulanic acid 875 mg 1-0-1 for three days. Pivmecillinam is an antibiotic of the first choice for uncomplicated cystitis. More side effects are risked with amoxicillin and clavulanic acid.


Cefpodoxime 100 mg 1-0-1 for 3 days. Alternatives: cefuroxim, cefdinir or cefaclor. Cephalosporins cause ESBL resistance or Clostridium difficile infections. They are second-line agents, e.g., in case of contraindications or treatment failure.

Trimethoprim or Cotrimoxazole:

200 mg trimethoprim or 960 mg cotrimoxazole (trimethoprim 160 mg combined with sulfamethoxazole 800 mg), dosage twice a day for three days. First choice antibiotic due to its good tolerance, but regional high resistance levels are up to 30%.


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. Caution: Due to dangerous side effects, fluoroquinolones are third-choice antibiotics in uncomplicated UTIs and are only approved if no alternative therapy exists.

Treatment of Uncomplicated Cystitis in Men or Complicated Cystitis in Women

A urine culture should be started before initiating treatment with cotrimoxazole, fluoroquinolones, or oral cephalosporin for seven 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 safe antibiotics are amoxicillin 250 mg 1-1-1 p.o. or an oral cephalosporin such as cefpodoxime 100–200 mg 1-0-1 or cefuroxime 500 mg 1-0-1 for three days. Bacteriuria without symptoms should be treated during pregnancy since the risk for 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 treatment for 7–10 days. The following antibiotics are suitable for children: cotrimoxazole, oral cephalosporins, and amoxicillin. The dosage depends on body weight.

Treatment of Fungal Bladder Infection (Candida Cystitis)

Asymptomatic funguria should not be treated; antibody titer may help in treatment decisions. Clinical significant bladder infection are treated with 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). The following measures reduce the risk of bladder infection: micturition after sexual intercourse, high diuresis, no diaphragm or spermicide for contraception, and avoidance of anal intercourse.

If the prevention mentioned above is ineffective, a single dose of antibiotics (cephalosporine, cotrimoxazole, 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). The proposed mechanisms are the interaction of cranberry juice with the adherence abilities of the bacteria with the urothelium and bacteriostatic properties. Overall, trials are contradictory and the therapeutic effect in adults may be low (Jepson et al., 2012). Several randomized studies have shown that cranberry juice is effective in children.

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) is more successful and less harmful than oral hormone replacement therapy. Dosage: 0,03–0,5 mg intravaginal estriol once a week.

Vaccination against Recurrent Bladder Infection

Oral vaccination with inactivated but immunogenic E. coli strains (e.g., Uro-Vaxom) shows a reduction of UTI recurrence within 6–12 months by 22–65%. Dosage: one capsula p.o. over three months (Bauer et al., 2002).

Parenteral vaccination:

An intramuscular vaccination has also shown effectiveness in controlled studies with a reduction in UTI recurrences and breakthrough infections between 26–93% compared to placebo (Vahlensieck et al., 2014). Dosage of Strovac or Perison: three IM injections for basic immunization every two weeks, one refreshment injection after one year, if successful.


A nutritional supplement to reduce UTI, 2 g d-mannose daily reduces (RR 0,24) the recurrence of UTI (Kranjcec et al., 2014). Urinary excretion of d-mannose occupies the fimbriae of the coliform bacteria and reduces the adherence to the urothelium.

Low-Dose Antibiotic Prophylaxis

Low-dose antibiotic prophylaxis is considered an effective method for preventing recurrent urinary tract infections in patients with high levels of distress or complications. The dosage is once a day in the evening; alternatively, it can be taken once after sexual intercourse. Possible drugs and dosages: nitrofurantoin 50–100 mg, trimethoprim 50–100 mg, cotrimoxazole 240–480 mg. Long-term prophylactic use of fluoroquinolones such as ofloxacin, ciprofloxacin, or norfloxacin is not permitted. Problems are the side effects, increasing resistance, and the frequently unchanged recurrence rate after the termination of antibiotic prophylaxis (Kranz et al., 2017).

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


G. Bonkat, R. Bartoletti, F. Bruyère, S. E. Geerlings, F. Wagenlehner, and B. Wullt, “EAU Guideline: Urological Infections.” [Online]. Available: https://uroweb.org/guidelines/urological-infections/

Bauer, H. W.; Rahlfs, V. W.; Lauener, P. A. & Blessmann, G. S. Prevention of recurrent urinary tract infections with immuno-active E. coli fractions: a meta-analysis of five placebo-controlled double-blind studies 2002, 19, 451-6.

Leitlinienprogramm DGU Interdisziplinäre S3 Leitlinie: Epidemiologie, Diagnostik, Therapie, Prävention und Management unkomplizierter, bakterieller, ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten. Langversion 1.1-2. AWMF Registernummer: 043/044
2017. https://www.awmf.org//uploads/tx_szleitlinien/043-044l_S3_Harnwegsinfektionen_2017-05.pdf

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

Jepson, R. G.; Williams, G. & Craig, J. C. Cranberries for preventing urinary tract infections.
Cochrane Database Syst Rev, 2012, 10, CD001321.

Nickel 2005a NICKEL, J. C.: Management of urinary tract infections: historical perspective and current strategies: Part 1–Before antibiotics.
In: J Urol
173 (2005), Nr. 1, S. 21–6

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

Vahlensieck, W.; Bauer, H.-W.; Piechota, H. J.; Ludwig, M. & Wagenlehner, F. [Prophylaxis of recurrent urinary tract infections]. Urologe A, 2014, 53, 1468-1475.

  Deutsche Version: Diagnose und Therapie der akuten Zystitis