Nonantibiotic therapy for acute cystitis in nonpregnant adult females younger than 65 years

Many adult females younger than 65 years who are treated symptomatically (without antibiotic therapy) for acute cystitis become symptom free within 1 weekHoffmann, 2020.

The risk of acute pyelonephritis or sepsis following cystitis is low (estimated 1 to 5%)Carey, 2020. The risk is reduced by antibiotic therapyCarey, 2020Jansaker, 2022Bjerrum, 2015Gágyor, 2015Kronenberg, 2017. It has been estimated that for every 20 to 60 females with cystitis managed without antibiotics, one would progress to pyelonephritisCarey, 2020.

Antibiotic therapy is associated with more rapid symptom resolution than nonantibiotic therapy; however, the absolute difference in symptom duration, on average, is small (a few days). It has been estimated that 3 to 6 female patients need to receive an antibiotic to have one extra patient symptom free on day 3Carey, 2020.

For nonpregnant adult females younger than 65 years with mild symptoms of acute cystitis who do not have immune compromise, consider a trial of nonantibiotic therapy to manage symptoms and avoid the adverse effects associated with antibiotic therapyNational Institute for Health and Care Excellence (NICE), October 2018. See Considerations for nonantibiotic therapy for acute cystitis for considerations when deciding whether to recommend nonantibiotic therapy for acute cystitis.

Note: For nonpregnant adult females younger than 65 years with mild symptoms of acute cystitis, who do not have immune compromise, consider a trial of nonantibiotic therapy.
Figure 1. Considerations for nonantibiotic therapy for acute cystitis

Hoffmann, 2021

When considering nonantibiotic therapy for acute cystitis, discuss the following with the patient.

  • Many people who do not take antibiotics will become symptom free within 1 week.
  • Symptoms resolve faster with antibiotics but the difference is small.
  • Complications from cystitis are rare, but an antibiotic can reduce the risk.
  • Antibiotics can cause adverse effects including:
    • diarrhoea, rash or more serious hypersensitivity reactions
    • disrupting the balance of bacteria in the body (the microbiome) and causing problems ranging from mild yeast infections (eg thrush) through to more serious infections (eg Clostridioides difficile [formerly known as Clostridium difficile])
    • bacteria becoming resistant to treatment so that future infections are harder to treat.

If a decision is made to use nonantibiotic therapy:

  • provide the patient with information on
    • symptom management (eg pain relief with a NSAID)
    • when to seek medical advice for worsening infection (eg fever 38°C or higher, rigors, loin or back pain, vomiting)
  • consider offering a delayed prescription for antibiotic therapy with clear instruction on when to start the antibiotic (eg in 3 days if symptoms do not start to improve, or earlier if symptoms worsen).
Note:

NSAID = nonsteroidal anti-inflammatory drug

Analgesia with a nonsteroidal anti-inflammatory drug (NSAID) is the most common nonantibiotic therapy for acute cystitis; see Oral drugs for mild, acute nociceptive pain in adults for information about adverse effects of NSAIDsBjerrum, 2015Gágyor, 2015. A suitable regimen for acute cystitis isCarey, 2020:

ibuprofen 400 mg orally, 8-hourly for up to 3 days. ibuprofen ibuprofen ibuprofen

Patients taking a NSAID for analgesia are less likely to start an antibiotic when also provided with a delayed antibiotic prescription, compared to patients who do not use a NSAIDCarey, 2020.

Some clinicians send a midstream urine sample, if indicated, and use analgesia while awaiting results of urine microscopy, culture and susceptibility testing. An antibiotic prescription tailored to the susceptibility results of the isolate can then be provided if requiredNational Institute for Health and Care Excellence (NICE), October 2018.