Difference between revisions of "Acute cystitis"

(Leukocyte Esterase)
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**[[Abdominal pain]]
**[[Abdominal pain]]
**[[Altered mental status]]
**[[Altered mental status]]
*''Suspect [[pyelonephritis]], infected kidney stone, or other disease process in patients who have inadequate or atypical response to treatment''
;Suspect [[pyelonephritis]], infected kidney stone, or other disease process in patients who have inadequate or atypical response to treatment
==Differential Diagnosis==
==Differential Diagnosis==

Revision as of 03:25, 14 August 2019

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


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.


  • 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)


Clinical Features



Differential Diagnosis


Pelvic Pain

Pelvic origin

Abdominal origin




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
    • High WBCs w/o bacteria, consider TB, Chlamydia, Appendicitis

Leukocyte Esterase

  • Found in PMNs
  • High sensitivity
  • Low specificity


  • 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


  • 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


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


Inpatient Options



  • Admit for inability to tolerate PO


Special Populations


  • 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


  • 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


  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.
  3. Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.