Diagnosis and Handling of Astute Unproblematic Cystitis

RICHARD COLGAN, Md, and MOZELLA WILLIAMS, MD, Academy of Maryland Schoolhouse of Medicine, Baltimore, Maryland

Am Fam Dr.. 2011 Oct 1;84(7):771-776.

Patient information: See related handout on treating a float infection (cystitis), written by the authors of this article.

Article Sections

  • Abstruse
  • Diagnosis
  • Self-Diagnosis and Diagnosis by Phone
  • Physical Examination and Diagnostic Testing
  • International Clinical Practice Guidelines
  • Treatment
  • Antimicrobial Resistance
  • References

Urinary tract infections are the about mutual bacterial infections in women. Near urinary tract infections are astute uncomplicated cystitis. Identifiers of acute simple cystitis are frequency and dysuria in an immunocompetent adult female of childbearing age who has no comorbidities or urologic abnormalities. Physical examination is typically normal or positive for suprapubic tenderness. A urinalysis, but non urine civilisation, is recommended in making the diagnosis. Guidelines recommend three options for first-line treatment of acute uncomplicated cystitis: fosfomycin, nitrofurantoin, and trimethoprim/sulfamethoxazole (in regions where the prevalence of Escherichia coli resistance does not exceed 20 per centum). Beta-lactam antibiotics, amoxicillin/clavulanate, cefaclor, cefdinir, and cefpodoxime are not recommended for initial treatment considering of concerns about resistance. Urine cultures are recommended in women with suspected pyelonephritis, women with symptoms that do non resolve or that recur inside two to four weeks afterward completing treatment, and women who nowadays with atypical symptoms.

Urinary tract infections (UTIs) are the most common bacterial infections in women, with one-half of all women experiencing at to the lowest degree 1 UTI in their lifetime.1 Most UTIs in women are acute uncomplicated cystitis caused by Escherichia coli (86 percent), Staphylococcus saprophyticus (4 percent), Klebsiella species (3 percent), Proteus species (3 pct), Enterobacter species (ane.4 pct), Citrobacter species (0.8 pct), or Enterococcus species (0.5 percent).two Although acute uncomplicated cystitis may not be idea of as a serious condition, patients' quality of life is often significantly affected. Acute uncomplicated cystitis results in an estimated half-dozen days of discomfort leading to approximately seven 1000000 office visits per year with associated costs of $1.6 billion.3,iv In one study of women with acute uncomplicated cystitis, virtually one-half of participants reported that their symptoms acquired them to miss piece of work or school.3 Additionally, upward to one-one-half of those with acute uncomplicated cystitis besides reported avoiding sexual activity for an average of one week.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Prove rating References

The combination of new-onset frequency and dysuria, with the absenteeism of vaginal discharge, is diagnostic for a urinary tract infection.

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6

A urine culture is recommended for women with suspected acute pyelonephritis, women with symptoms that do not resolve or that recur within two to four weeks after the completion of treatment, and women who nowadays with atypical symptoms.

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11

First-line treatment options for acute uncomplicated cystitis include nitrofurantoin (macrocrystals; 100 mg twice per day for five days), trimethoprim/sulfamethoxazole (Bactrim, Septra; 160/800 mg twice per day for three days in regions where the uropathogen resistance is less than 20 per centum), and fosfomycin (Monurol; a unmarried 3-g dose).

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sixteen

Diagnosis

  • Abstract
  • Diagnosis
  • Self-Diagnosis and Diagnosis by Telephone
  • Physical Examination and Diagnostic Testing
  • International Clinical Practice Guidelines
  • Treatment
  • Antimicrobial Resistance
  • References

The history is the almost of import tool for diagnosing acute uncomplicated cystitis, and it should be supported past a focused physical examination and urinalysis. It as well is important to dominion out a more than serious complicated UTI. By definition, the diagnosis of astute uncomplicated cystitis implies an uncomplicated UTI in a premenopausal, nonpregnant woman with no known urologic abnormalities or comorbidities (Table 15).

Table ane.

Characteristics of Patients with Elementary and Complicated Urinary Tract Infections

Uncomplicated

Immunocompetent

No comorbidities

No known urologic abnormalities

Nonpregnant

Premenopausal

Complicated*

History of childhood urinary tract infections

Immunocompromised

Preadolescent or postmenopausal

Pregnant

Underlying metabolic disorder (e.g., diabetes mellitus)

Urologic abnormalities (due east.k., stones, stents, indwelling catheters, neurogenic bladder, polycystic kidney disease)

Classic lower urinary tract symptoms include dysuria, frequent voiding of pocket-size volumes, and urinary urgency. Sometimes hematuria tin occur; suprapubic discomfort is less common. The pretest probability of UTI in women is v percent; nonetheless, when a woman presents with the acute onset of even one of the classic symptoms of acute uncomplicated cystitis, the probability of infection rises 10-fold to 50 percent.half dozen Therefore, presentation with i or more symptoms may be viewed as a valuable diagnostic test in itself. In addition, the likelihood of astute unproblematic cystitis is less if the patient reports vaginal discharge or irritation, both of which are more likely in women with vaginitis or cervicitis. The new onset of frequency and dysuria, with the absence of vaginal discharge or irritation, has a positive predictive value of 90 percentage for UTI.6 A prospective report of 796 sexually active young women identified take chances factors to assistance diagnose UTI, including recent sexual intercourse, diaphragm use with spermicide, and recurrent UTIs.7

Self-Diagnosis and Diagnosis by Telephone

  • Abstruse
  • Diagnosis
  • Self-Diagnosis and Diagnosis by Phone
  • Physical Examination and Diagnostic Testing
  • International Clinical Do Guidelines
  • Treatment
  • Antimicrobial Resistance
  • References

For many patients, access to care can be hard. Two recent studies have shown that some women who cocky-diagnose a UTI may exist treated safely with phone direction. Women who take had acute uncomplicated cystitis previously are usually accurate in determining when they are having another episode. In 1 study of 172 women with a history of recurrent UTI, 88 women self-diagnosed a UTI based on symptoms, and self-treated with antibiotics.8 Laboratory evaluation showed that 84 percent of the urine samples showed a uropathogen, xi percent showed sterile pyuria, and simply 5 percent were negative for pyuria and bacteriuria. Another small, randomized controlled trial compared outcomes of acute simple cystitis in healthy women managed by telephone versus in the part.9 At that place were no differences in symptom score or satisfaction. The authors concluded that the short-term outcomes of managing suspected UTIs past telephone were comparable with those managed past usual function intendance.

Physical Test and Diagnostic Testing

  • Abstract
  • Diagnosis
  • Self-Diagnosis and Diagnosis by Telephone
  • Concrete Examination and Diagnostic Testing
  • International Clinical Practise Guidelines
  • Handling
  • Antimicrobial Resistance
  • References

The concrete exam of patients with astute uncomplicated cystitis is typically normal, except in the 10 to 20 pct of women with suprapubic tenderness.10 Acute pyelonephritis should be suspected if the patient is sick-appearing and seems uncomfortable, specially if she has concomitant fever, tachycardia, or costovertebral angle tenderness.

The convenience and cost-effectiveness of urine dipstick testing makes it a mutual diagnostic tool, and it is an advisable culling to urinalysis and urine microscopy to diagnose acute unproblematic cystitis.11 Nitrites and leukocyte esterase are the well-nigh authentic indicators of acute simple cystitis in symptomatic women.11 To avert contamination, the convention is to utilize a midstream, clean-catch urine specimen to diagnose UTI; however, at least two studies accept shown no meaning difference in number of contaminated or unreliable results between specimens collected with and without preparatory cleansing.12,13 Urine cultures are recommended simply for patients with suspected astute pyelonephritis; patients with symptoms that do not resolve or that recur within 2 to four weeks afterwards the completion of treatment; and patients who nowadays with atypical symptoms.11 A colony count greater than or equal to 103 colony-forming units per mL of a uropathogen is diagnostic of acute elementary cystitis.14 However, studies accept shown that more xii colony-forming units per mL in women with typical symptoms of a UTI correspond a positive culture.15 Routine posttreatment urinalysis or urine cultures in asymptomatic patients are not necessary.

Further studies beyond urinalysis and urine cultures are rarely needed to diagnose acute simple cystitis. Patients who present with singular symptoms of acute uncomplicated cystitis and those who practice not respond to appropriate antimicrobial therapy may need imaging studies, such equally computed tomography or ultrasonography, to rule out complications and other disorders.

International Clinical Practice Guidelines

  • Abstruse
  • Diagnosis
  • Self-Diagnosis and Diagnosis past Telephone
  • Physical Examination and Diagnostic Testing
  • International Clinical Practice Guidelines
  • Treatment
  • Antimicrobial Resistance
  • References

In 2010, a panel of international experts updated the 1999 Infectious Diseases Gild of America (IDSA) guidelines on the treatment of acute uncomplicated cystitis and pyelonephritis in women. The panel reviewed the literature, including the Cochrane Database of Systematic Reviews, and provided an evidence-based guideline for women with simple bacterial cystitis and pyelonephritis.16,17 The IDSA collaborated with the European Society of Clinical Microbiology and Infectious Diseases, and invited representation from diverse geographic areas and a wide variety of specialties, including urology, obstetrics and gynecology, emergency medicine, family medicine, internal medicine, and infectious diseases. Levels-of-evidence ratings were assigned to recommendations on the use of antimicrobials for the treatment of elementary UTIs.

Treatment

  • Abstract
  • Diagnosis
  • Self-Diagnosis and Diagnosis by Telephone
  • Concrete Examination and Diagnostic Testing
  • International Clinical Practise Guidelines
  • Treatment
  • Antimicrobial Resistance
  • References

No single agent is considered best for treating acute uncomplicated cystitis according to the 2010 guidelines, and the selection between recommended agents should exist individualized16 (Table twoeighteen,19). Choosing an antibiotic depends on the agent's effectiveness, risks of adverse effects, resistance rates, and propensity to crusade collateral damage (i.e., ecologic adverse effects of antibiotic therapy that may let drug-resistant organisms to proliferate, and the colonization or infection with multidrug-resistant organisms). Additionally, physicians should consider cost, availability, and specific patient factors, such as allergy history. On boilerplate, patients will begin noting symptom relief within 36 hours of beginning treatment.2

Table two.

Antimicrobial Agents for the Direction of Acute Uncomplicated Cystitis

Tier Drug Dosage Cost of generic (brand) Pregnancy category

Start

Fosfomycin (Monurol)

3-chiliad single dose

NA ($51)*

B

Nitrofurantoin (macrocrystals)

100 mg twice per day for five days

$55 ($64)*

B

Trimethoprim/sulfamethoxazole (Bactrim, Septra)

160/800 mg twice per mean solar day for three days

$17 ($34)*†

C

Second

Ciprofloxacin (Cipro)

250 mg twice per day for three days

$26 ($30)†‡

C

Ciprofloxacin, extended release (Cipro XR)

500 mg per mean solar day for three days

$57 ($76)*

C

Levofloxacin (Levaquin)

250 mg per twenty-four hours for three days

NA ($86)*

C

Ofloxacin

200 mg per day for three days

$14 (NA)‡

C

or

400-mg unmarried dose

$10 (NA)‡

Third§

Amoxicillin/clavulanate (Augmentin)

500/125 mg twice per day for vii days

$32 ($98)*

B

Cefdinir (Omnicef)

300 mg twice per day for x days

$40 ($119)*

B

Cefpodoxime

100 mg twice per day for 7 days

$71 (NA)‡

B

There are several outset-line agents recommended by the IDSA for the treatment of acute simple cystitis (Figure 1).sixteen New evidence supports the utilise of nitrofurantoin (macrocrystals) and fosfomycin (Monurol) as first-line therapy.16 The post-obit antimicrobials represent the offset tier: (1) nitrofurantoin at a dosage of 100 mg twice per day for five days; (2) trimethoprim/sulfamethoxazole (Bactrim, Septra) at a dosage of i double-strength tablet (160/800 mg) twice per solar day for three days in regions where the prevalence of resistance of customs uropathogens does non exceed xx percent; and (3) fosfomycin at a single dose of three thousand. Note that the elapsing of therapy for nitrofurantoin has been reduced to five days compared with the previous IDSA guidelines of 7 days, based on research showing effectiveness with a shorter duration of therapy.20 Fosfomycin may exist less effective and is not widely bachelor in the United States.

Choosing an Antimicrobial Agent for Empiric Handling of Astute Uncomplicated Cystitis

Figure 1.

Algorithm for choosing an antimicrobial agent for empiric treatment of acute uncomplicated cystitis.

Adjusted with permission from Gupta Yard, Hooton TM, Naber KG, et al. International clinical do guidelines for the treatment of astute unproblematic cystitis and pyelonephritis in women: a 2010 update past the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e104.

Fluoroquinolones (i.e., ofloxacin, ciprofloxacin [Cipro], and levofloxacin [Levaquin]) are considered 2d-tier antimicrobials, and are appropriate in some settings, such as in patients with allergy to the recommended agents. Although fluoroquinolones are effective, they have the propensity for collateral impairment, and should be considered for patients with more serious infections than acute uncomplicated cystitis. Certain antimicrobials (i.eastward., beta-lactam antibiotics, amoxicillin/clavulanate [Augmentin], cefdinir [Omnicef], cefaclor, and cefpodoxime) may exist appropriate alternatives if recommended agents cannot be used because of known resistance or patient intolerance. Despite wide use of cranberry products for treating UTIs, there is no evidence to support their use in symptomatic patients.21

Antimicrobial Resistance

  • Abstract
  • Diagnosis
  • Self-Diagnosis and Diagnosis by Phone
  • Physical Test and Diagnostic Testing
  • International Clinical Do Guidelines
  • Treatment
  • Antimicrobial Resistance
  • References

Beta-lactam antibiotics are non recommended as offset-line therapy for acute uncomplicated cystitis because of widespread E. coli resistance rates above xx percent. Fluoroquinolone resistance usually is found to be below ten percent in North America and Europe, simply with a trend toward increasing resistance over the past several years.16 To preserve the effectiveness of fluoroquinolones, they are not recommended as a first-tier pick. Fosfomycin and nitrofurantoin have retained high rates of in vitro activity in well-nigh areas.sixteen

Because results of urine cultures are non routinely reported when treating acute uncomplicated cystitis, local resistance rates may non exist available. Defaulting to the annual antimicrobial sensitivity data from a local hospital may provide resistance rates based on a population that does not reflect women with elementary astute elementary cystitis (east.g., sicker patients, inpatients, patients of all ages, male patients). Several studies have been published that may help predict the likelihood of E. coli resistance to trimethoprim/sulfamethoxazole in patients with astute simple cystitis. Use of trimethoprim/sulfamethoxazole in the preceding 3 to six months has been found to be an independent risk factor for resistance in women with acute elementary cystitis.22,23 In improver, ii U.S. studies demonstrated that travel outside the Us in the preceding iii to half dozen months was independently associated with trimethoprim/sulfamethoxazole resistance.24,25

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The Authors

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RICHARD COLGAN, MD, is an associate professor and director of medical student educational activity in the Department of Family unit and Customs Medicine at the University of Maryland Schoolhouse of Medicine in Baltimore....

MOZELLA WILLIAMS, MD, is an assistant professor and assistant managing director of medical student education in the Department of Family and Community Medicine at the University of Maryland School of Medicine.

Address correspondence to Richard Colgan, MD, University of Maryland School of Medicine, 29 South Paca St., Baltimore, MD 21201 (electronic mail: rcolgan@som.umaryland.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disembalm.

The authors thank Kalpana Gupta, Physician, for her review of the manuscript.

REFERENCES

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3. Colgan R, Keating K, Dougouih M. Survey of symptom burden in women with uncomplicated urinary tract infections. Clin Drug Investig. 2004;24(1):55–lx.

4. Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Am J Med. 2002;113(suppl 1A):5S–13S.

5. Nicolle L; AMMI Canada Guidelines Committee. Complicated urinary tract infection in adults. Can J Infect Dis Med Microbiol. 2005;16(6):349–360.

6. Aptitude S, Nallamothu BK, Simel DL, Fihn SD, Saint Due south. Does this woman take an acute elementary urinary tract infection? JAMA. 2002;287(20):2701–2710.

vii. Hooton TM, Scholes D, Hughes JP, et al. A prospective study of gamble factors for symptomatic urinary tract infection in immature women. N Engl J Med. 1996;335(seven):468–474.

8. Gupta K, Hooton TM, Roberts PL, Stamm WE. Patient-initiated treatment of elementary recurrent urinary tract infections in young women. Ann Intern Med. 2001;135(1):9–16.

9. Barry HC, Hickner J, Ebell MH, Ettenhofer T. A randomized controlled trial of phone management of suspected urinary tract infections in women. J Fam Pract. 2001;50(7):589–594.

10. Stamm We. Urinary tract infections. In: Root RK, Waldvogel F, Corey L, Stamm WE. Clinical Infectious Diseases: A Practical Approach. New York, NY: Oxford Academy Printing; 1999:649–656.

11. Colgan R, Hyner South, Chu S. Uncomplicated urinary tract infections in adults. In: Grabe M, Bishop MC, Bjerklund-Johansen, et al., eds. Guidelines on Urological Infections. Arnhem, The Netherlands: European Association of Urology; 2009:11–38.

12. Bradbury SM. Collection of urine specimens in general practise: to clean or non to clean? J R Coll Gen Pract. 1988;38(313):363–365.

13. Lifshitz Eastward, Kramer L. Outpatient urine civilisation: does collection technique matter? Arch Intern Med. 2000;160(xvi):2537–2540.

xiv. Stamm WE. Criteria for the diagnosis of urinary tract infection and for the assessment of therapeutic effectiveness. Infection. 1992;twenty(suppl iii):S151–S154.

fifteen. Kunin CM. Guidelines for urinary tract infections. Rationale for a carve up strata for patients with "low-count" bacteriuria. Infection. 1994;22(suppl ane):S38–S40.

16. Gupta K, Hooton TM, Naber KG, et al. International clinical practise guidelines for the treatment of acute simple cystitis and pyelonephritis in women: a 2010 update past the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103–e120.

17. Zalmanovici Trestioreanu A, Light-green H, Paul K, Yaphe J, Leibovici 50. Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database Syst Rev. 2010;(x):CD007182.

eighteen. Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. Am Fam Physician. 2005;72(3):451–456.

nineteen. American College of Obstetricians and Gynecologists. ACOG Practice Message No. 91: treatment of urinary tract infections in nonpregnant women. Obstet Gynecol. 2008;111(iii):785–794.

20. Gupta K, Hooton TM, Roberts PL, Stamm Nosotros. Curt-course nitrofurantoin for the treatment of acute elementary cystitis in women. Arch Intern Med. 2007;167(20):2207–2212.

21. Jepson RG, Mihaljevic L, Craig J. Cranberries for treating urinary tract infections. Cochrane Database Syst Rev. 2000;(2):CD001322.

22. Brown PD, Freeman A, Foxman B. Prevalence and predictors of trimethoprim-sulfamethoxazole resistance among uropathogenic Escherichia coli isolates in Michigan. Clin Infect Dis. 2002;34(viii):1061–1066.

23. Metlay JP, Strom BL, Asch DA. Prior antimicrobial drug exposure: a gamble factor for trimethoprim-sulfamethoxazole-resistant urinary tract infections. J Antimicrob Chemother. 2003;51(4):963–970.

24. Burman WJ, Breese PE, Murray BE, et al. Conventional and molecular epidemiology of trimethoprim-sulfamethoxazole resistance amongst urinary Escherichia coli isolates. Am J Med. 2003;115(5):358–364.

25. Colgan R, Johnson JR, Kuskowski M, Gupta K. Risk factors for trimethoprim-sulfamethoxazole resistance in patients with astute unproblematic cystitis. Antimicrob Agents Chemother. 2008;52(3):846–851.

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