Difference between revisions of "Acute cystitis"
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+ | ''This page is for adult patients; see [[urinary tract infection (peds)]] for pediatric patients.'' | ||
==Background== | ==Background== | ||
{{UTI types}} | {{UTI types}} | ||
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===Complicated=== | ===Complicated=== | ||
+ | ''Suspect [[pyelonephritis]], infected kidney stone, or other disease process in patients who have inadequate or atypical response to treatment'' | ||
*May not have classic symptoms | *May not have classic symptoms | ||
**[[Weakness]] | **[[Weakness]] | ||
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**[[Abdominal pain]] | **[[Abdominal pain]] | ||
**[[Altered mental status]] | **[[Altered mental status]] | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
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{{Dysuria DDX}} | {{Dysuria DDX}} | ||
− | == | + | ==Evaluation== |
− | ===UA=== | + | ===Urine Analysis (UA)=== |
====WBC count==== | ====WBC count==== | ||
*WBC >5 in patient with appropriate symptoms is diagnostic | *WBC >5 in patient with appropriate symptoms is diagnostic | ||
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**WBC 1-2 with bacteriuria can be significant in men | **WBC 1-2 with bacteriuria can be significant in men | ||
***More likely represents [[urethritis]] or [[prostatitis]] from [[STI]] | ***More likely represents [[urethritis]] or [[prostatitis]] from [[STI]] | ||
+ | **High WBCs w/o bacteria, consider TB, [[Chlamydia]], [[Appendicitis]] | ||
+ | |||
+ | ====Leukocyte Esterase==== | ||
+ | *Found in PMNs | ||
+ | *High sensitivity | ||
+ | *Low specificity | ||
====Nitrite==== | ====Nitrite==== | ||
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*Consider local resistance patterns (if >10-20% use a different agent) | *Consider local resistance patterns (if >10-20% use a different agent) | ||
*Avoid use of fluoroquinolones for uncomplicated cystitis if possible | *Avoid use of fluoroquinolones for uncomplicated cystitis if possible | ||
− | *Consider phenazopyridine 100-200mg TID after meals x 2 days for pain control (bladder analgesic) | + | *Consider [[phenazopyridine]] 100-200mg TID after meals x 2 days for pain control (bladder analgesic) |
;Complicated if: | ;Complicated if: | ||
*Symptoms >7days | *Symptoms >7days | ||
− | *[[ | + | *[[Diabetes mellitus]] |
*Urinary tract infection in previous 4wk | *Urinary tract infection in previous 4wk | ||
*Men | *Men | ||
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===Complicated=== | ===Complicated=== | ||
+ | *Consider admission for period of observation and/or culture results | ||
==Special Populations== | ==Special Populations== | ||
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===Pregnant Women=== | ===Pregnant Women=== | ||
*Treat all cases of asymptomatic bacteriuria | *Treat all cases of asymptomatic bacteriuria | ||
+ | |||
+ | ==Pearls<ref>Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.</ref>== | ||
+ | *In female patients with dysuria, consider vaginitis (trichomoniasis, candidiasis) or urethritis (N. gonorrheae/Chlamydia) | ||
+ | *Elderly patients with pyelonephritis: 20% present with primary respiratory or GI symptoms. Also 33% are afebrile. | ||
+ | *[[Phenazopyridine]] for dysuria symptoms: Be sure to warn of discoloration of urine and tears. Don’t wear contact lens due to risk of staining. | ||
==See Also== | ==See Also== |
Revision as of 03:28, 14 August 2019
This page is for adult patients; see urinary tract infection (peds) for pediatric patients.
Contents
Background
Genitourinary infection
"UTI" frequently refers specifically to acute cystitis, but may also be used as a general term for all urinary infections; use location-specific diagnosis.
- Acute cystitis ("UTI")
- Pyelonephritis
- Urethritis
- Chronic cystitis
- Infected nephrolithiasis
- Prostatitis
- Renal abscess/perinephric abscess
- Emphysematous pyelonephritis
Definitions
- Relapse
- Recurrence of symptoms within month despite treatment
- Caused by same organism and represents treatment failure
- Recurrence of symptoms within month despite treatment
- Reinfection
- Development of symptoms 1-6mo after treatment
- Usually due to a different organism
- If patient has >3 recurrences in 1 yr consider tumor, calculi, diabetes
Risk Factors
- Anatomic abnormality of urinary tract or external drainage system
- Indwelling urinary catheter, stent
- Nephrolithiasis, neurogenic bladder, polycystic renal disease, recent instrumentation
- Recurrent acute cystitis
- Advanced age in men (BPH, recent instrumentation, recent prostatic biopsy)
- Nursing home residency
- Neonatal
- Comorbidities (DM, sickle cell disease)
- Pregnancy
- Immunosuppression (AIDS, immunosuppressive drugs)
- Advanced neurologic disease (CVA with disability, Spinal Cord Injuries)
Microbiology
- Most common pathogen is E. coli
- Anaerobic organisms are rarely pathogenic (do not grow well in urine)
- Complicated acute cystitis is more likely to be caused by pseudomonas or enterococcus
Clinical Features
Uncomplicated
Complicated
Suspect pyelonephritis, infected kidney stone, or other disease process in patients who have inadequate or atypical response to treatment
- May not have classic symptoms
Differential Diagnosis
Major
- Pyelonephritis
- Infected kidney stone
Pelvic Pain
Pelvic origin
- Urinary tract infection
- Ectopic
- Ovarian torsion
- Endometriosis
- Pelvic inflammatory disease
- Cervicitis
- Ectopic pregnancy
- Ovarian torsion
- Spontaneous abortion
- Septic abortion
- Myoma (degenerating)
- Ovarian cyst (rupture)
- Tubo-ovarian abscess
- Mittelschmerz
- Sexual assault/trauma
- Ovarian hyperstimulation syndrome
Abdominal origin
- Appendicitis
- Kidney stone
- Psoas abscess
- Mesenteric adenitis
- Incarcerated hernia
- Diverticulitis
- Pyelonephritis
Dysuria
- Genitourinary infection
- Acute cystitis ("UTI")
- Pyelonephritis
- Urethritis
- Chronic cystitis
- Infected nephrolithiasis
- Prostatitis
- Epididymitis
- Renal abscess/perinephric abscess
- Emphysematous pyelonephritis
- Nephrolithiasis
- Urethral issue
- Urethritis
- Urolithiasis
- Urethral foreign body
- Urethral diverticulum
- Allergic reaction (contact dermatitis)
- Chemical irritation
- Urethral stricture or obstruction
- Trauma to vagina, urethra, or bladder
- Gynecologic
- Vaginitis/cervicitis
- PID
- Genital herpes
- Uterine/bladder/vaginal prolapse
- Fistula
- Cystocele
- Other
- Diverticulitis
- Behavioral symptom without detectable pathology
Evaluation
Urine Analysis (UA)
WBC count
- WBC >5 in patient with appropriate symptoms is diagnostic
- Lower degrees of pyuria may still be clinically significant in presence of symptoms
- False negative may be due to: dilute urine, systemic leukopenia, obstruction
- WBC 1-2 with bacteriuria can be significant in men
- More likely represents urethritis or prostatitis from STI
- High WBCs w/o bacteria, consider TB, Chlamydia, Appendicitis
- Lower degrees of pyuria may still be clinically significant in presence of symptoms
Leukocyte Esterase
- Found in PMNs
- High sensitivity
- Low specificity
Nitrite
- Very high specificity (>90%) in confirming diagnosis
- Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected)
Urine Culture
- Indicated for:
- Complicated acute cystitis
- Pyelonephritis
- Pregnant women
- Children
- Adult males
- Relapse/reinfection
Blood Culture
- Not indicated
- Organisms in blood cultures matched those in urine cultures 97% of time
Management
- Consider local resistance patterns (if >10-20% use a different agent)
- Avoid use of fluoroquinolones for uncomplicated cystitis if possible
- Consider phenazopyridine 100-200mg TID after meals x 2 days for pain control (bladder analgesic)
- Complicated if
- Symptoms >7days
- Diabetes mellitus
- Urinary tract infection in previous 4wk
- Men
- >65 years old
- Women who use spermicides or diaphragm
- Relapse
- Pregnancy
Outpatient
Women, Uncomplicated
- Nitrofurantoin ER 100mg BID x 5d, OR
- TMP/SMX DS (160/800mg) 1 tab BID x 3d, OR
- Cephalexin 250mg QID x 5d, OR
- Ciprofloxacin 250mg BID x3d
- Avoid using fluoroquinolone for the first-line treatment of uncomplicated urinary tract infections (UTIs) in women.[1]
- Fosfomycin 3 g PO once
- Lower clinical and microbiologic success compared to nitrofurantoin TID for 5 days [2]
Women, Complicated
- Ciprofloxacin 500mg BID x10-14d, OR
- Cefpodoxime 200 mg BID x10-14d
Women, Concern for Urethritis
- Ceftriaxone 250mg IM x1 AND azithromycin 1gm PO x1 AND nitrofurantoin ER 100mg BID x5d, OR
- Levofloxacin 500mg QD x 14d (covers urinary pathogens, GC, and chlamydia)
- GC resistance to fluoroquinolones is increasing
Men
- Ciprofloxacin 500mg BID x10-14d, OR
- Cefpodoxime 200 mg BID x10-14d
Inpatient Options
- Ciprofloxacin 400mg IV q12hr, OR
- Ceftriaxone 1gm IV QD, OR
- Cefotaxime 1-2gm IV q8hr, OR
- Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr, OR
- Piperacillin/Tazobactam 3.375 gm IV q6hr, OR
- Cefepime 2gm IV q8hr, OR
- Imipenem 500mg IV q8hr
Disposition
Uncomplicated
- Admit for inability to tolerate PO
Complicated
- Consider admission for period of observation and/or culture results
Special Populations
AIDS
- TMP-SMX resistance is increased due to its use in PCP pneumonia prophylaxis
- Fluoroquinolones should be initial antibiotic of choice
- Most acute cystitis is caused by typical pathogens or common STI organisms
Pregnant Women
- Treat all cases of asymptomatic bacteriuria
Pearls[3]
- In female patients with dysuria, consider vaginitis (trichomoniasis, candidiasis) or urethritis (N. gonorrheae/Chlamydia)
- Elderly patients with pyelonephritis: 20% present with primary respiratory or GI symptoms. Also 33% are afebrile.
- Phenazopyridine for dysuria symptoms: Be sure to warn of discoloration of urine and tears. Don’t wear contact lens due to risk of staining.
See Also
References
- ↑ Choosing Wisely. American Urogynecologic Society. http://www.choosingwisely.org/societies/american-urogynecologic-society
- ↑ Huttner, A., Kowalczyk, A., Turjeman, A., Babich, T., Brossier, C., Eliakim-Raz, N., … Harbarth, S. (2018). Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(17), 1781–1789.
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
Authors:
adam haag, Daniel Eggeman, Claire, Michael Hwang, Neil Young, Daniel Ostermayer, Ross Donaldson