• 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.

In depth

• Follow local guidelines when available.
• If local guidelines are not available:
• For an uncomplicated infection, prescribe either:
• Trimethoprim 200 mg twice daily, for 3 days, or
• Nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for 3 days.
• For a complicated infection, prescribe a 5–10-day course of trimethoprim or nitrofurantoin.

In depth

• Urine microscopy and culture are not routinely required for women with uncomplicated cystitis.
• Send urine for microscopy and culture if any of the following apply:
• There are risk factors for a complicated urinary tract infection — for example the woman has recently had urological instrumentation, or is immunocompromised, or has been in hospital recently.
• Confirmation of the diagnosis or exclusion of other conditions is required.
• The woman has not responded to antibiotic treatment.
• The woman has recurrent episodes of cystitis and this has not been investigated.
• When underlying causes of recurrent cystitis and other conditions have been excluded, it is not necessary to routinely culture the urine for further episodes.

In depth

• Follow up is not routinely required for uncomplicated cystitis, but should be considered for women with a potentially complicated infection.
• If haematuria was found, follow up to re-test the urine and check that the infection and haematuria have resolved.

In depth

• If the woman fails to respond to two courses of antibiotics shown by urine culture results to be appropriate treatment, refer for specialist assessment.
• If urological cancer is suspected (for example haematuria persists after successful treatment of cystitis), refer urgently to a team specializing in the management of urological cancer.

In depth

• Continue symptomatic treatment with paracetamol or ibuprofen.
• Check compliance with antibiotic treatment.
• Send a urine sample for culture.
• If symptoms are troublesome, offer a different antibiotic (nitrofurantoin or trimethoprim) while waiting for the culture results — see Choice of antibiotic.
• If infection is confirmed on culture, treat with an antibiotic to which the organism is sensitive.
• If infection is not confirmed on culture, consider other possible causes for the symptoms — see Differential diagnosis.
• If cystitis symptoms fail to respond to two courses of antibiotic shown by culture to be appropriate treatment, refer for specialist assessment.

In depth