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== | ||
{{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]] | ||
===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=== | |||
*May not have classic symptoms | |||
**[[Weakness]] | |||
**[[Fever]] | |||
**[[Abdominal pain]] | |||
**[[Altered mental status]] | |||
;Suspect [[pyelonephritis]], infected kidney stone, or other disease process in patients who have inadequate or atypical response to treatment | |||
==Differential Diagnosis== | |||
===Major=== | |||
*[[Pyelonephritis]] | |||
*Infected [[kidney stone]] | |||
{{Pelvic pain DDX}} | |||
{{Dysuria DDX}} | |||
== | ==Evaluation== | ||
===UA=== | |||
====WBC count==== | |||
*WBC >5 in | *WBC >5 in patient with appropriate symptoms is diagnostic | ||
**Lower degrees of pyuria may still be clinically significant in presence of | **Lower degrees of pyuria may still be clinically significant in presence of symptoms | ||
***False negative may be due to: dilute urine, systemic leukopenia, obstruction | ***False negative may be due to: dilute urine, systemic leukopenia, obstruction | ||
**WBC 1-2 | **WBC 1-2 with bacteriuria can be significant in men | ||
***More likely represents urethritis or [[prostatitis]] from [[STI]] | ***More likely represents [[urethritis]] or [[prostatitis]] from [[STI]] | ||
**High WBCs w/o bacteria, consider TB, [[Chlamydia]], [[Appendicitis]] | |||
=====Nitrite | ====Leukocyte Esterase==== | ||
*Very high specificity (>90%) in confirming diagnosis | *Found in PMNs | ||
*High specificity | |||
*Low sensitivity | |||
====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]] 100-200mg TID after meals x 2 days for pain control (bladder analgesic) | |||
; | ;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=== | ||
==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=== | ||
*Treat all cases of asymptomatic bacteriuria | *Treat all cases of asymptomatic bacteriuria | ||
==Pearls<ref>Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.</ref>== | |||
*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== | ==See Also== | ||
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*[[UTI (Peds)]] | *[[UTI (Peds)]] | ||
== | ==References== | ||
<references/> | |||
[[Category:Renal]] | |||
[[Category: | |||
[[Category:ID]] | [[Category:ID]] | ||
[[Category: | [[Category:Urology]] |
Revision as of 16:25, 19 February 2018
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
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
- May not have classic symptoms
- Suspect pyelonephritis, infected kidney stone, or other disease process in patients who have inadequate or atypical response to treatment
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
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
- 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 specificity
- Low sensitivity
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 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
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.[2]
- Fosfomycin 3 g PO once
- Lower clinical and microbiologic success compared to nitrofurantoin TID for 5 days [3]
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
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
- Treat all cases of asymptomatic bacteriuria
Pearls[4]
- 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
References
- ↑ 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.
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.