Acute cystitis: Difference between revisions
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''This page is for adult patients; see [[urinary tract infection (peds)]] for pediatric patients.''
==Background==
==Background==
*Also known as acute cystitis; abbreviation = UTI
[[File:2605 The Bladder.jpg|thumb|Anatomy of the bladder (male)]]
*Men <50 yr: symptoms of dysuria or urinary frequency usually due to [[STI]]
{{UTI types}}
*Men >50 yr: incidence of UTI rises dramatically d/t prostatic obstruction
*Uncomplicated UTI:
**No structural or functional abnormalities w/in urinary tract or kidney
**No relevant comorbidities that place pt at risk for more serious adverse outcome
**Not associated with GU tract instrumentation


===Definitions===
===Definitions===
*UTI = significant bacteriuria in presence of symptoms
**Described by location: urethritis, cystitis, or pyelonephritis
*Relapse
*Relapse
**Recurrence of symptoms w/in month despite tx
**Recurrence of symptoms within month despite treatment
***Caused by same organism and represents treatment failure
***Caused by same organism and represents treatment failure
*Reinfection
*Reinfection
**Development of symptoms 1-6mo after tx
**Development of symptoms 1-6mo after treatment
**Usually due to a different organism
**Usually due to a different organism
**If pt has >3 recurrences in 1 yr consider tumor, calculi, [[diabetes]]
**If patient has >3 recurrences in 1 yr consider tumor, calculi, [[diabetes]]


===Risk factors for complicated UTI===
===Risk Factors===
*Male sex
**In young males dysuria is more commonly do to [[STI]]
**Suspect underlying anatomic abnormality in men with culture-proven UTI
*Anatomic abnormality of urinary tract or external drainage system
*Anatomic abnormality of urinary tract or external drainage system
**Indwelling urinary catheter, stent
**Indwelling urinary catheter, stent
**Nephrolithiasis, neurogenic bladder, polycystic renal disease, recent instrumentation
**[[Nephrolithiasis]], neurogenic bladder, polycystic renal disease, recent instrumentation
*Recurrent UTI (three or more per year)
*Recurrent acute cystitis
*Advanced age in men (BPH, recent instrumentation, recent prostatic biopsy)
*Advanced age in men (BPH, recent instrumentation, recent prostatic biopsy)
*Nursing home residency (w/ or w/o indwelling bladder catheter)
*Nursing home residency
*Neonatal state
*Neonatal  
*Comorbidities ([[DM]], sickle cell disease)
*Comorbidities ([[DM]], [[sickle cell disease]])
*Pregnancy
*[[Pregnancy]]
*Immunosuppression ([[AIDS]], immunosuppressive drugs)
*Immunosuppression ([[AIDS]], immunosuppressive drugs)
*Advanced neurologic disease ([[CVA]] w/ disability, [[Spinal Cord Injuries]])
*Advanced neurologic disease ([[CVA]] with disability, [[Spinal Cord Injuries]])
*Known or suspected atypical pathogens (Non–[[E. coli]] infection)
*Known or suspected abx resistance (resistance to [[cipro]] predicts multidrug resistance)


===[[Microbiology]]===
===[[Microbiology]]===
*Most common pathogen is [[E. coli]]
*Most common pathogen is [[E. coli]]
*[[Anaerobic]] organisms are rarely pathogenic (do not grow well in urine)
*[[Anaerobic]] organisms are rarely pathogenic (do not grow well in urine)
*Complicated UTIs more likely to be caused by [[pseudomonas]] or [[enterococcus]]
*Complicated acute cystitis is more likely to be caused by [[pseudomonas]] or [[enterococcus]]


==Diagnosis==
==Clinical Features==
===Clinical Features===
===Uncomplicated===
*UTI dx requires both bacteriuria and clinical symptoms
*[[Dysuria]]
**Cystitis = Dysuria, [[hematuria]], frequency, urgency, suprapubic pain, CVAT
*[[hematuria]]
**Pyelo = Cystitis sx AND fever/chills/nausea/vomiting
*Frequency
***CVAT alone may be referred pain from cystitis
*Urgency
***CVAT is only physical examination finding that increases likelihood of a UTI
*Suprapubic pain
*Urethritis
**In males more likely due to [[chlamydia]]/[[GC]]
**In females more likely due to [[chlam]]/[[GC]] if:
***Stuttering urination symptoms
***New sex partner or partner w/ urethritis
***Signs/symptoms cervicitis
***Sterile pyuria
*Complicated UTI
**Pts may not have classic symptoms; may only have [[weakness]], [[fever]], [[abd pain]], [[AMS]]
===Labs===
====UA====
=====WBC count=====
*WBC >5 in pt w/ appropriate symptoms is diagnostic
**Lower degrees of pyuria may still be clinically significant in presence of UTI sx
***False negative may be due to: dilute urine, systemic leukopenia, obstruction
**WBC 1-2 w/ bacteriuria can be significant in men
***More likely represents urethritis or [[prostatitis]] from [[STI]]


=====Nitrite=====
===Complicated===
*Very high specificity (>90%) in confirming diagnosis of UTI
''Suspect [[pyelonephritis]], infected kidney stone, or other disease process in patients who have inadequate or atypical response to treatment''
*Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected)
*May not have classic symptoms
====[[Urine Culture]]====
**[[Weakness]]
*Indicated for:
**[[Fever]]
**Complicated UTI
**[[Abdominal pain]]
**Pyelonephritis
**[[Altered mental status]]
**Pregnant women
**Children
**Adult males
**Relapse/reinfection
====[[Blood Culture]]====
*Not indicated
**Organisms in blood cx matched those in urine cx 97% of time
 
===Imaging===
*Consider if [[pyelonephritis]] and any of the following:
#History of [[Renal Stone]]
#Poor response to [[antibiotics]]
#Male
#Elderly
#[[Diabetic]]
#Severely ill


==Differential Diagnosis==
==Differential Diagnosis==
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*Infected [[kidney stone]]
*Infected [[kidney stone]]


===Pelvic Pain===
{{Pelvic pain DDX}}
{{Pelvic pain DDX}}


===Dysuria===
{{Dysuria DDX}}
{{Dysuria DDX}}
==Evaluation==
[[File:Pyuria2011.jpg|thumb|Urine with pyuria.]]
===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, recent antibiotic use with incomplete treatment
**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]]
====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==
==Management==
*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]] for dysuria symptoms
**100-200mg TID after meals x 2 days for pain control (bladder analgesic)
**Warn of discoloration of urine and tears. Don’t wear contact lens due to risk of staining.<ref>Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.</ref>


;Consider longer course of complicated cystitis if:
;Complicated if:
*Symptoms >7d
*Symptoms >7days
*[[DM]]
*[[Diabetes mellitus]]
*UTI in previous 4wk
*Urinary tract infection in previous 4wk
*Men
*Men
*Age 65 yr
*>65 years old
*Women who use spermicides or diaphragm
*Women who use spermicides or diaphragm
*Relapse
*Relapse
*Pregnancy
*Pregnancy


{{UTI Antibiotics}}
{{Acute cystitis antibiotics}}


==Disposition==
==Disposition==
===Uncomplicated UTI===
===Uncomplicated===
*Admit
*Admit for inability to tolerate PO
**Unable to tolerate PO
*Discharge
**Consider phenazopyridine 100-200mg TID after meals x2d only (bladder analgesic)
===[[Pyelonephritis]]===
*Discharge
**Consider if young, otherwise healthy, tolerating PO
*Admission
**Consider if elderly, [[Renal Calculi]], obstruction, recent hospitalization/instrumentation, [[DM]]


==Complications==
===Complicated===
*Suspect in pts who have inadequate or atypical response to tx for presumed [[pyelonephritis]]
*Consider admission for period of observation and/or culture results
#Acute bacterial nephritis
##CT shows ill-defined focal areas of decreased density
#Renal/Perinephric Abscesses
##Sign/symptoms similar to [[pyelo]] ([[fever]], CVAT, dysuria)
##Occurs in setting of ascending infection w/ obstructed pyelo
##Associated w/ [[DM]] and [[Renal Stones]]
##Also occurs due to bacteremia w/ hematogenous seeding (Staph)
#Emphysematous pyelonephritis
##Rare gas-forming infection nearly always occurring in pts w/ [[DM]] and obstruction
###Pts appear toxic and [[septic]]; nephrectomy may be required


==Special Populations==
==Special Populations==
===[[AIDS]]===
===[[AIDS]]===
*[[TMP-SMX]] resistance is increased due to its use in [[PCP PNA]] prophylaxis
*[[TMP-SMX]] resistance is increased due to its use in [[PCP pneumonia]] prophylaxis
**[[Fluoroquinolones]] should be initial antibiotic of choice
**[[Fluoroquinolones]] should be initial antibiotic of choice
*Most UTIs are caused by typical pathogens or common STI organisms
*Most acute cystitis is caused by typical pathogens or common [[STI]] organisms
 
===Pregnant Women===
===Pregnant Women===
*Treat all cases of asymptomatic bacteriuria
*Treat all cases of asymptomatic bacteriuria
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*[[Urinary tract infections]]
*[[Urinary tract infections]]
*[[UTI (Peds)]]
*[[UTI (Peds)]]
*[[Dysuria]]
==Source ==
*


[[Category:Nephro]]
==References==
<references/>
[[Category:Renal]]
[[Category:ID]]
[[Category:ID]]
[[Category:GU]]
[[Category:Urology]]

Revision as of 09:35, 2 May 2020

This page is for adult patients; see urinary tract infection (peds) for pediatric patients.

Background

Anatomy of the bladder (male)

Genitourinary infection

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.

"UTI" frequently refers specifically to acute cystitis, but may also be used as a general term for all urinary infections; use location-specific diagnosis.

Definitions

  • Relapse
    • Recurrence of symptoms within month despite treatment
      • Caused by same organism and represents treatment failure
  • 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

Clinical Features

Uncomplicated

Complicated

Suspect pyelonephritis, infected kidney stone, or other disease process in patients who have inadequate or atypical response to treatment

Differential Diagnosis

Major

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Dysuria

Evaluation

Urine with pyuria.

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, recent antibiotic use with incomplete treatment
    • WBC 1-2 with bacteriuria can be significant in men
    • High WBCs w/o bacteria, consider TB, Chlamydia, Appendicitis

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

Management

  • Consider local resistance patterns (if >10-20% use a different agent)
  • Avoid use of fluoroquinolones for uncomplicated cystitis if possible
  • Consider phenazopyridine for dysuria symptoms
    • 100-200mg TID after meals x 2 days for pain control (bladder analgesic)
    • Warn of discoloration of urine and tears. Don’t wear contact lens due to risk of staining.[2]
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.[3]
  • Fosfomycin 3 g PO once
    • Lower clinical and microbiologic success compared to nitrofurantoin TID for 5 days [4]

Women, Complicated

Women, Concern for Urethritis

Men

Inpatient Options

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
  • Most acute cystitis is caused by typical pathogens or common STI organisms

Pregnant Women

  • Treat all cases of asymptomatic bacteriuria

See Also

References

  1. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  2. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  3. ↑ Choosing Wisely. American Urogynecologic Society. http://www.choosingwisely.org/societies/american-urogynecologic-society
  4. ↑ 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.
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