• Convey a positive approach and reassure the woman that cystitis is generally self-limiting:
• Without antibiotics, symptoms can be expected to resolve in 4–9 days.
• With antibiotics, symptoms can be expected to resolve in 3–8 days.
• On average, antibiotics shorten the duration of symptoms by about a day.
• Relieve symptoms with paracetamol or ibuprofen — do not recommend urine alkalinizing agents or cranberry products.
• If cystitis symptoms are moderate or severe:
• Offer an antibiotic.
• Do not dipstick test the urine, as the decision to offer an antibiotic is not influenced by urine dipstick test results. Even if the tests for nitrite, and leucocyte esterase, and blood are all negative, an antibiotic should still be offered.
• If the woman prefers not to take an antibiotic, offer a delayed antibiotic prescription to be dispensed if the symptoms become worse, or last more than 48 hours.
• If cystitis symptoms are mild:
• Dipstick test the urine to guide treatment decisions.
• Discuss not using an antibiotic, especially if the urine dipstick test is negative for nitrites and leucocyte esterase and blood.
• Have a lower threshold for offering an antibiotic if there are risk factors for persistent infection, recurrent infection, or treatment failure.
• If there are concerns about not taking an antibiotic, offer a delayed antibiotic prescription to be dispensed if the symptoms become worse, or last more than 48 hours.
• Advise the woman to seek medical attention if she develops a high fever or becomes systemically unwell.

These recommendations are in line with Scottish [SIGN, 2006], European [European Association of Urology, 2009], and American [ICSI, 2004; American College of Obstetricians and Gynecologists, 2008] guidelines. The recommendations also take into account the evidence from a Health Technology Assessment (HTA) commissioned by the National Institute for Health Research (NIHR) to assess the diagnosis of cystitis, its prognosis, and five different treatment strategies [Little et al, 2009].

A positive approach to prognosis

• A positive approach to diagnosis and prognosis has been found to be independently associated with shorter duration of symptoms in observational studies and in randomized controlled trials [Thomas, 1987; Little et al, 2001; Little et al, 2009].
• The average duration of symptoms (that are at least moderately severe) is reported in the NIHR HTA [Little et al, 2009] and summarized in the Prognosis section.

Use of an analgesic for symptomatic relief

• CKS found no trials of analgesics for the painful symptoms of cystitis. The recommendation to use paracetamol or ibuprofen to treat the painful symptoms of cystitis is based on their use in other painful infections and the experience of experts [SIGN, 2006].
• There is insufficient evidence to recommend the use of:
• Urine alkalinizing agents (such as potassium citrate or bicarbonate): CKS found no controlled trials of urine alkalinizing agents. One observational study found no relationship between symptoms of cystitis and urine pH [Brumfitt et al, 1990].
• Cranberry products: a Cochrane systematic review found no good evidence to support the use of cranberry juice or other cranberry products for treating acute UTIs [Jepson et al, 1998].

Treatment strategy (to consider the options of an antibiotic, no antibiotic, or delayed antibiotic prescription)

• The evidence that a course of antibiotics is effective is discussed in Choice of antibiotic.
• The strategy for antibiotic prescribing is supported by evidence from a series of studies in the UK [Little et al, 2009], and a randomized controlled trial in New Zealand [Richards et al, 2005].
• No clinically (or economically) important differences were found between five different treatment strategies in which antibiotics were offered: (i) immediately, (ii) delayed for 48 hours, (iii) according to a symptom rule, (iv) according to a dipstick test rule, or (v) according to the results of urine culture.
• Women who did not meet the criteria for immediate antibiotic treatment were offered a delayed antibiotic prescription to use if their symptoms did not settle after 48 hours. In each group where women were offered a delayed prescription, a high proportion chose to use it.
• Women who presented with more severe symptoms of dysuria, urgency, frequency, and nocturia recovered more slowly.
• Antibiotics shortened the duration of symptoms (that were at least moderately severe) by about 1–2 days.
• CKS therefore recommends offering an antibiotic when:
• Presenting symptoms are moderate or severe — because antibiotics are likely to shorten the duration of symptoms by 1–2 days.
• The woman has a strong preference for antibiotic treatment — because there is no evidence that treatment leads to poorer outcomes, although there is also no evidence of effectiveness in women with less severe symptoms.
• It may be a complicated infection — because there is a greater risk of adverse effects from infection.
• While CKS recommends using severity of symptoms as a key decision criterion, other guidelines (for example [SIGN, 2006]) recommend using number of symptoms.
• CKS recommends considering a delayed antibiotic prescription whenever an antibiotic is not prescribed, because this may give some women the confidence needed to try not using an antibiotic, to see if the symptoms resolve spontaneously.