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== | ||
[[File:2605 The Bladder.jpg|thumb|Anatomy of the bladder (male)]] | |||
{{UTI types}} | {{UTI types}} | ||
===Definitions=== | ===Definitions=== | ||
*Relapse | *Relapse | ||
**Recurrence of symptoms | **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 | **Development of symptoms 1-6mo after treatment | ||
**Usually due to a different organism | **Usually due to a different organism | ||
**If | **If patient has >3 recurrences in 1 yr consider tumor, calculi, [[diabetes]] | ||
**For menopausal or postmenopausal women with recurrent infection consider empiric treatment for [[Atrophic_vaginitis|genitourinary syndrome of menopause]] (GSM)<ref>Winter et al, UTIs and Estrogen: the Overlooked Link https://www.acepnow.com/article/utis-and-estrogen-the-overlooked-link/</ref> | |||
===Risk | ===Risk Factors=== | ||
*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 | *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 | *Nursing home residency | ||
*Neonatal | *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]] | *Advanced neurologic disease ([[CVA]] with disability, [[Spinal Cord Injuries]]) | ||
===[[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 | *Complicated acute cystitis is more likely to be caused by [[pseudomonas]] or [[enterococcus]] | ||
== | ==Clinical Features== | ||
=== | ===Uncomplicated=== | ||
*[[Dysuria]] | |||
*[[hematuria]] | |||
* | *Frequency | ||
** | *Urgency | ||
*Suprapubic pain | |||
=== | ===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 | |||
* | **[[Weakness]] | ||
** | **[[Fever]] | ||
** | **[[Abdominal pain]] | ||
** | **[[Altered mental status]] | ||
=====Nitrite | ==Differential Diagnosis== | ||
*Very high specificity (>90%) in confirming diagnosis | ===Major=== | ||
*[[Pyelonephritis]] | |||
*Infected [[kidney stone]] | |||
{{Pelvic pain 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) | *Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected) | ||
===[[Urine Culture]]=== | |||
*Indicated for: | *Indicated for: | ||
**Complicated acute cystitis | **Complicated acute cystitis | ||
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**Relapse/reinfection | **Relapse/reinfection | ||
===[[Blood Culture]]=== | |||
*Not indicated | *Not indicated | ||
**Organisms in blood | **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> | |||
; | ;Complicated if: | ||
*Symptoms > | *Symptoms >7days | ||
*[[ | *[[Diabetes mellitus]] | ||
* | *Urinary tract infection in previous 4wk | ||
*Men | *Men | ||
* | *>65 years old | ||
*Women who use spermicides or diaphragm | *Women who use spermicides or diaphragm | ||
*Relapse | *Relapse | ||
*Pregnancy | *Pregnancy | ||
{{ | {{Acute cystitis antibiotics}} | ||
==Disposition== | ==Disposition== | ||
===Uncomplicated | ===Uncomplicated=== | ||
*Admit | *Admit for inability to tolerate PO | ||
== | ===Complicated=== | ||
*Consider admission for period of observation and/or culture results | |||
==Special Populations== | ==Special Populations== | ||
===[[AIDS]]=== | ===[[AIDS]]=== | ||
*[[TMP-SMX]] resistance is increased due to its use in [[PCP | *[[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 acute cystitis is caused by typical pathogens or common [[STI]] organisms | *Most acute cystitis is caused by typical pathogens or common [[STI]] organisms | ||
===Pregnant Women=== | ===Pregnant Women=== | ||
* | *New ACOG guidelines: If asymptomatic, get a culture and only treat if >100k CFUs<ref>Urinary Tract Infections in Pregnant Individuals | ||
Clinical Consensus. Number 4, August 2023. https://www.acog.org/clinical/clinical-guidance/clinical-consensus/articles/2023/08/urinary-tract-infections-in-pregnant-individuals</ref> | |||
==See Also== | ==See Also== | ||
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*[[UTI (Peds)]] | *[[UTI (Peds)]] | ||
== | ==References== | ||
<references/> | |||
[[Category:Renal]] | |||
[[Category: | |||
[[Category:ID]] | [[Category:ID]] | ||
[[Category: | [[Category:Urology]] |
Latest revision as of 16:25, 1 November 2023
This page is for adult patients; see urinary tract infection (peds) for pediatric patients.
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.
- Renal/perirenal
- Ureteral
- Infected urolithiasis
- Bladder
- Acute cystitis ("UTI")
- Chronic cystitis
- Urethra/periurethra
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
- For menopausal or postmenopausal women with recurrent infection consider empiric treatment for genitourinary syndrome of menopause (GSM)[1]
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
Acute Pelvic Pain
Gynecologic/Obstetric
- Pregnancy-related
- Ectopic Pregnancy
- Spontaneous abortion, threatened or incomplete
- Septic abortion
- Acute Infections
- Vulvovaginitis
- Adnexal Disorders
- Hemorrhage/rupture of ovarian cyst
- Ovarian torsion
- Twisted paraovarian cyst
- Other
- Myoma (degenerating)
- Genitourinary trauma
- Ovarian hyperstimulation syndrome
- Sexual assault
- Recurrent
- Mittelschmerz
- Primary/Secondary Dysmenorrhea
- Pelvic Congestion Syndrome
- Endometriosis
Genitourinary
Gastrointestinal
- Gastroenteritis
- Appendicitis
- Bowel obstruction
- Perirectal abscess
- Diverticulitis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
Musculoskeletal
- Abdominal wall hematoma
- Psoas hematoma, psoas abscess
- Hernia
Vascular
- Pelvic thrombophlebitis
- Abdominal aortic aneurysm
- Ischemic bowel (Mesenteric Ischemia)
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
- Pelvic organ prolapse
- Fistula
- Cystocele
- Other
- Diverticulitis
- Interstitial cystitis
- 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, 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
- 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 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.[3]
- 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.[4]
- Fosfomycin 3 g PO once
- Lower clinical and microbiologic success compared to nitrofurantoin TID for 5 days [5]
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
- New ACOG guidelines: If asymptomatic, get a culture and only treat if >100k CFUs[6]
See Also
References
- ↑ Winter et al, UTIs and Estrogen: the Overlooked Link https://www.acepnow.com/article/utis-and-estrogen-the-overlooked-link/
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
- ↑ 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.
- ↑ Urinary Tract Infections in Pregnant Individuals Clinical Consensus. Number 4, August 2023. https://www.acog.org/clinical/clinical-guidance/clinical-consensus/articles/2023/08/urinary-tract-infections-in-pregnant-individuals