Treatment Recommendations for Appropriate Use

Treatment Recommendations for Appropriate Use

General Principles

  • Fosfomycin is an oral antibiotic that is approved for treatment of uncomplicated cystitis, and may be a convenient option to use in select patients with cystitis caused by drug-resistant organisms who would otherwise require IV therapy
  • Clinical efficacy of fosfomycin is comparable to other first-line agents for UTI, however microbiological efficacy may be lower
  • Patients should be closely monitored for recurrence

Fosfomycin is only approved for documented MDROs where there are no other oral alternatives

  • Generally not covered by insurances
  • May require prior authorization (PA) to obtain coverage

Recommend MTM pharmacist consult

Fosfomycin Use

  • Uncomplicated cystitis
    • Cystitis in healthy non-pregnant female
  • Complicated cystitis
    • Indwelling catheter, or catheter removed within 48 hours
    • Males
    • Immunosuppression
    • Neurologic/functional abnormalities (e.g. neurogenic bladder, obstructive uropathy)
    • Pregnant females (NOTE: Category B & per studies, one dose of fosfomycin sufficient in this population)
  • Pyelonephritis, bacteremia, patients with nephrostomy tubes or renal stones
  • Empiric treatment of cystitis when first line agents can be used


Patient is not a candidate for the following first line alternatives:

  • Nitrofurantoin (do not use if CrCL < 30 mL/min)
  • Amoxicillin (can be used if isolate is ampicillin sensitive)
  • Tetracycline
  • Doxycycline
  • Linezolid

The patient is not a candidate for the following oral options based on sensitivities, drug allergies, or contraindications:

  • Nitrofurantoin (do not use if CrCL < 30 mL/min)
  • Fluoroquinolones
  • Beta-lactams

Request fosfomycin sensitivities from microbiology lab (858-554-9734)