Difference between revisions of "Acute cystitis"

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**Development of symptoms 1-6mo after treatment
 
**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]]
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**If patient has >3 recurrences in 1 yr consider tumor, calculi, [[diabetes]]
  
 
===Risk Factors===
 
===Risk Factors===

Revision as of 13:17, 2 July 2016

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.

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 w/ 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

Pelvic Pain

Pelvic origin

Abdominal origin

Dysuria

Diagnosis

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

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 100-200mg TID after meals x 2 days for pain control (bladder analgesic)
Complicated if
  • Symptoms >7days
  • DM
  • 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

Women, Concern for Urethritis

Men

Inpatient Options

Disposition

Uncomplicated

  • Admit for inability to tolerate PO

Complicated

Special Populations

AIDS

  • TMP-SMX resistance is increased due to its use in PCP PNA 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. Choosing Wisely. American Urogynecologic Society. http://www.choosingwisely.org/societies/american-urogynecologic-society
  2. 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.