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.

• Acute cystitis ("UTI")
• Pyelonephritis
• Urethritis
• Chronic cystitis
• Infected nephrolithiasis
• Prostatitis
• Renal abscess/perinephric abscess
• Emphysematous pyelonephritis

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 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

• 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

Pelvic origin

• Urinary Tract Infection
• Ectopic
• Ovarian torsion
• Endometriosis
• PID
• Cervicitis
• Ectopic Pregnancy
• Ovarian Torsion
• Spontaneous abortion
• Septic abortion
• Myoma (degenerating)
• Ovarian cyst (rupture)
• Tubo-ovarian abscess
• Mittelschmerz
• Sexual assault/trauma
• Ovarian hyperstimulation syndrome

Abdominal origin

• Appendicitis
• Kidney stone
• Psoas abscess
• Mesenteric adenitis
• Incarcerated hernia
• Diverticulitis
• Pyelonephritis

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
  • Uterine/bladder/vaginal prolapse
  • Fistula
  • Cystocele
• Other
  • Diverticulitis
  • 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

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
• 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.

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

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

See Also

• Urinary tract infections
• UTI (Peds)

References

Authors

Ross Donaldson, Christopher Kim