Inflammation of the Bladder (Cystitis): Drug Therapy

Therapeutic target

  • Treatment of the bacterial infection and thus avoidance of complications.

Therapy recommendations

  • Please note the different recommendations for the following patient groups with uncomplicated UTI (urinary tract infection).
    • A. Non-pregnant women in premenopause (stage of life: approximately ten to fifteen years before menopause/very last menstrual period) without other relevant concomitant diseases.
    • B. Pregnant women without other relevant concomitant diseases.
    • C. Postmenopausal women (period that begins when menstruation has been absent for at least one year) without other relevant concomitant diseases (local vaginal prophylactic estrogen therapy; see below).
    • D. Younger men without other relevant concomitant diseases.
    • E. Patients with diabetes mellitus and stable metabolic status without other relevant concomitant diseases.
  • Children: calculated antibiotic therapy best immediately after confirming the diagnosis to avoid parenchymal damage to the kidneys (see below pyelonephritis / drug therapy).
  • See also under “Further therapy”.

Subsequent recommendations relate to cystitis. For information on pyelonephritis, see the topic of the same name. Notes on therapy (guidelines)

  • A. Nonpregnant premenopausal women (life stage: approximately ten to fifteen years before menopause/very last menstrual period) without other relevant concomitant diseases:
    • Asymptomatic bacteriuria is often found in routine examinations of nonpregnant women without other relevant concomitant diseases. Asymptomatic bacteriuria should not be treated in this group. (Ia-A)
  • B. Pregnant women without other relevant concomitant diseases:
    • Acute uncomplicated cystitis in pregnant women: the pathogen spectrum and resistance rates are similar to those in nonpregnant premenopausal women (IIA).
  • C. Postmenopausal women without other relevant comorbidities:
  • D. Younger men without other relevant comorbidities:
    • Urinary tract infections in men should usually be assessed as complicated infections because the prostate may be involved as a parenchymatous organ (IIb-B).
    • In urinary tract infections in men should always be a differentiated clarification! (V-B)
    • Asymptomatic bacteriuria in younger men without other relevant concomitant diseases should not be treated with antibiotics. (V-A)
    • When an indication for antibiotic therapy is made in men with a urinary tract infection, a urine culture should be performed before initiation of therapy and treated accordingly for resistance (V-B)
  • E. Patients with diabetes mellitus and stable metabolic status without other relevant concomitant diseases:
    • In patients with diabetes mellitus without other relevant diseases/complicating factors, urinary tract infections can be considered uncomplicated in stable metabolic status. (Ib)
    • Urinary tract infections in patients with diabetes mellitus and unstable metabolic status can be problematic because they may increase insulin resistance and worsen an unstable metabolic situation. (IIB)

Indications for antibiotic therapy

  • Acute uncomplicated UTI:
    • Antibiotic therapy should be recommended for acute uncomplicated cystitis. In patients with mild/moderate symptoms, symptomatic therapy alone may be considered as an alternative to antibiotic treatment. Participatory decision making with patients is necessary. (Ia-B)
    • If the oral bioavailability of the antibiotic is very good or good, oral antibiotic therapy should be preferred. (V-A)
    • Fluoroquinolones and cephalosporins should not be used as first-line antibiotics for uncomplicated cystitis. (V-A)
    • Preference should be given to one of the following antibiotics for uncomplicated cystitis: Fosfomycin–trometamol, nitrofurantoin, nitroxolin, pivmecillinam, trimethoprim* (in alphabetical order). * for resistance rates < 20% (Ia-A).
    • The following antibiotics should not be used as first-line agents in the treatment of uncomplicated cystitis: Cefpodoxime proxetil, ciprofloxacin, cotrimoxazole, levofloxacin, norfloxacin, ofloxacin (in alphabetical order). (Ia-A)
  • Acute uncomplicated urinary tract infections in pregnant women without other relevant concomitant diseases.
    • For acute uncomplicated urinary tract infections in pregnant women without other relevant concomitant diseases, penicillin derivatives, cephalosporins, or fosfomycin–trometamol should be used primarily. (V-B)
    • Asymptomatic bacteriuria in pregnant women increases the risk of developing a urinary tract infection. Evidence for harm to the child is not available. Of the symptomatic UTIs, acute cystitis is the most common, as it is in nonpregnant women. Antibiotic therapy for up to 7 days is usually recommended. (Ia-A)
    • For therapy, essentially fosfomycin trometamol (single therapy), pivmecillinam or oral cephalosporins group 2 or 3 are considered.
    • Asymptomatic bacteriuria in pregnant women increases the risk of developing a urinary tract infection. Evidence for harm to the child is not available. (Ia-A)
  • Acute uncomplicated urinary tract infections in postmenopausal patients without other relevant concomitant diseases.
    • Short-term therapy for acute cystitis is not as well established in postmenopausal as in premenopausal patients. However, studies are opening up the possibility for short-term therapy. (ib)
    • Antibiotic selection and dosing are consistent with treatment regimens for premenopausal women.
    • Postmenopausal women without other relevant comorbidities should not be screened for asymptomatic bacteriuria or given antibiotic therapy. (IIb-A)
  • Acute uncomplicated urinary tract infections in younger men without other relevant concomitant diseases.
    • For empiric oral therapy of acute uncomplicated cystitis in younger men, pivmecillinam and nitrofurantoin* should be used. * Prerequisite: no prostate involvement.
    • In younger men without other relevant concomitant diseases, neither screening for asymptomatic bacteriuria nor antibiotic therapy should be given.
  • Acute uncomplicated urinary tract infections in patients with diabetes mellitus and stable metabolic status without other relevant concomitant diseases.
    • Acute uncomplicated cystitis in patients with diabetes mellitus and a stable metabolic state (no tendency to hypoglycemia or hyperglycemia, no diabetic nephropathy and/or neuropathy) should be treated in the same way (choice of antibiotic and duration of therapy) as corresponding urinary tract infections in patients without diabetes mellitus. (V-B)
    • If insulin resistance is pronounced and organ complications are imminent, and if the patient is prone to metabolic decompensation, inpatient treatment should be considered. (V)
  • Before an expectedly mucosal traumatic urinary tract intervention, asymptomatic bacteriuria increases the risk of infection. Therefore, asymptomatic bacteriuria should be sought before such an intervention and treated if detected. (Ia-A)
  • Monitoring of treatment success of uncomplicated cystitis in premenopausal women without other relevant concomitant diseases is not necessary if they are symptom-free. (V)
  • Recurrent UTI (recurrent urinary tract infection):
    • For frequently recurrent cystitis in women, the immunoprophylactic drug UroVaxom (OM-89) should be used orally for 3 months before starting long-term antibiotic prevention. (Ia-B)
    • For frequently recurrent cystitis in women, the immunoprophylactic StroVac (formerly Solco-Urovac) can be used parenterally with 3 injections at weekly intervals before starting long-term antibiotic prevention. (Ib-C)
    • If there is an association with sexual intercourse, a single postcoital prevention should be given as an alternative to long-term antibiotic prevention.
    • For frequently recurrent cystitis in postmenopausal women, vaginal recurrence prevention with 0.5 mg estriol/day should be performed before starting long-term antibiotic prevention. (Ia-B)
    • Mannose (2 g of mannose per day in a glass of water) may be recommended for frequently recurrent cystitis in women. Alternatively, various phytotherapeutics (eg, preparations of bearberry leaves (maximum 1 month), capuchin herb, horseradish root), may be considered (see below phytotherapeutics).

Further notes

  • In recurrent cystitis (recurrent bladder infections) of postmenopausal women, vaginal estrogen therapy (vaginal therapy) should be performed before starting long-term antibiotic prevention [S3 guideline Peri- and Postmenopause – Diagnostics and Interventions].
  • In elderly patients, the risk of hyperkalemia (potassium excess) and acute renal failure is higher than with amoxicillin during the first 14 days after treatment with trimethoprim; mortality is not increased.
  • Symptomatic therapy of uncomplicated urinary tract infection with a nonsteroidal anti-inflammatory drug (NSAID):
    • In patients with an uncomplicated UTI and mild to moderate symptoms, symptomatic treatment with ibuprofen is often sufficient and the risk of complications appears to be low.
    • A randomized, double-blind trial involving 253 female patients with uncomplicated lower urinary tract infection (UTI) received either diclofenac or norfloxacin. The primary study endpoint, freedom from symptoms on day 3, was achieved by 54% of NSAID users and 80% of antibiotic users. It took a median of two days longer under NSAID than antibiotic therapy. Adverse events did not occur under antibiotic therapy, however under NSAID therapy 6 patients (5%) were diagnosed with pyelonephritis (inflammation of the renal pelvis)!
  • Drug Safety Communication: because of the risk of serious complications, antibiotics from the fluoroquinolone group should no longer be used to treat sinusitis, bronchitis, and uncomplicated urinary tract infections.
  • Antibacterial long-term infection prophylaxis in children (nitrofurantoin, trimethoprim; in case of intolerance in the first weeks of life: oral cephalosporins in reduced dose (about 1/5 of the therapeutic dose); indications are:
    • Infants and young children at high risk for developing parenchymal defects (tissue defects of the kidney) or urosepsis (blood poisoning: acute infection with bacteria from the genitourinary tract)
    • High risk of pyelonephritis recurrence (recurrence of pyelonephritis/renal pelvic inflammation).
    • Bladder dysfunction and recurrent symptomatic UTI.
    • Girls with frequent recurrent cystitis (recurrent bladder infections) and distress due to dysuric symptoms (e.g., painful urination)

Phytotherapeutics

  • Bearberry leaves* (maximum 1 month).
  • Watercress herb
  • Cranberry fruit → inhibition of adherence of P-fimbriae to the uroepithelium by proanthocyanidins.
  • Cranberry fruit
  • Capuchin herb (2 x 200 mg) → inhibition of Escherichia coli invasion into the urothelium (uroepithelial cell); antibacterial effect; restriction of use: children < 6 years.
  • Horseradish root (2 x 80 mg).
  • Centaury, lovage root, rosemary leaves → inhibition of adherence, diuretic effect; restriction of use: children < 12 years.
  • Combination of goldenrod, orthosiphon (also known as cat’s whiskers) and hauhechel → improvement of symptoms, esp. dysuria (painful or uncomfortable bladder emptying).

* Cave (Warning): is often offered together with sandalwood, which can cause kidney damage. Indication: acute uncomplicated cystitis.

Supplements (dietary supplements; vital substances)

Suitable dietary supplements wg cystitis (cystitis) should contain the following vital substances:

Suitable supplements for natural defense should contain the following vital substances:

Note: The listed vital substances are not a substitute for drug therapy. Dietary supplements are intended to supplement the general diet in the particular life situation.