Acute cystitis
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.