Acute cystitis

Revision as of 21:36, 22 February 2015 by Rossdonaldson1 (talk | contribs) (Diagnosis)

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 pt 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

Diagnosis

Clinical Features

  • Requires both bacteriuria and clinical symptoms
  • Complicated acute cystitis

Workup

UA

WBC count

  • WBC >5 in pt w/ 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 w/ 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

Differential Diagnosis

Major

Pelvic Pain

Pelvic origin

Abdominal origin

Dysuria

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

Complications

Suspect pyelonephritis in patients who have inadequate or atypical response to treatment

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

Source

  • 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.