Cystitis and Pyelonephritis in Women

Author: Michelle Lin, MD
Updated: 9/2/2011

Antibiotic Selection for Cystitis and Pyelonephritis in Women

2010 Infectious Disease Society of America (IDSA) and European Society for Microbiology and Infectious Diseases (ESMID) guidelines

Target population

  • Acute, uncomplicated cystitis and pyelonephritis in women
  • Premenopausal, non-pregnant women without known urological abnormalities or co-morbidities (i.e. DM)

Acute uncomplicated cystitis

  1. Nitrofurantoin (100 mg PO BID x 5 days)
  2. Trimethoprim-sulfamethoxazole (1 DS tab PO BID x 3 days)
    • Rising resistance rates
    • Only give if local antibiogram shows <20% resistance
  3. Fosfomycin(3 gm PO x 1)
    • Slightly less efficiacy compared to standard short-course regimens
  4. Pivmecillinam (400 mg PO BID x 3-7 days)
    • Only available in Europe
  5. Fluoroquinolones (3-day course of ofloxacin, ciprofloxacin, or levofloxacin)
    • Avoid if possible to minimize selection of drug-resistant organisms

Beta-lactams (3-7 day course of amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil)

  • Avoid if possible to minimize selection of drug-resistant organisms
  • Inferior efficacy compared with standard regimens
  • Cephalexin less well studied

Acute Pyelonephritis

Urine analysis and urine culture should always be performed

Ciprofloxacin (500 mg po BID x 7 days) +/- ciprofloxacin 400 mg IV x 1 dose If >10% resistance to fluoroquinolones, give 1-time IV dose:

  • Ceftriaxone 1 gm IV, or
  • An aminoglycoside

If <10% resistance rate, alternative oral fluoroquinolone outpatient dosing options:

  • Ciprofloxacin XR 1000 mg po daily x 7 days, or
  • Levofloxacin 750 mg po daily x 5 days

Trimethoprim-sulfamethoxazole (1 tab DS PO BID x 14 days) 1. If resistance rate unknown, give 1-time dose of ceftriaxone 1 gm IV or aminoglycoside first

Beta-lactams (10-14 day course) 1. Because of less efficacy, give 1-time dose of ceftriaxone 1 gm IV or aminoglycoside first

References

  • Gupta K et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the IDSA and the ESMID. Clin Infect Dis. 2011; 52(5). [PubMed]