CLINICAL ACTIONS:

Acute uncomplicated cystitis is often readily recognized by patients as a routine bladder infection.  Uncomplicated cystitis rarely progresses to pylonephritis and urosepsis even if untreated. The primary goal of treatment is to relieve symptoms. If a patient presents with pain, urgency and frequent urination

• Determine if a patient may have pyelonephritis as urine cultures are indicated in all cases of upper urinary tract infection (UTI)
  • Culture: Costo-vertebral angle tenderness | Fever | Chills | Flank pain | Nausea/ vomiting | Recurrent/ persistent symptoms despite treatment
• In the absence of signs and/or symptoms of pyelonephritis, cultures are not required
• Consider urinalysis in specific circumstances such as
  • Postmenopausal women who may have intermittent dysuria or urge incontinence without infection
  • Women without a previous history of UTI

• Women with previous history and recognize UTI symptoms can be treated empirically without urinalysis

Antibiotic Therapy

Note: ACOG has replaced Committee opinion 294 (2011) with Committee Opinion 717 (2017) that recommends the cautious use of sulfonamides and nitrofurantoin in the first trimester of pregnancy due to possible risk of birth defects, if no other alternatives are available (see ‘Related ObG Topics’ below)

• First-line therapy 
  • Trimethoprim-Sulfamethoxazole (TMP-SMX) 160-800 mg PO BID x 3 days
  • If resistance to TMP-SMX is > 15 to 20%
    • Fosfomycin 3 gm PO single dose
    • Trimethoprim 100 mg PO BID x 3 days
    • Nitrofurantoin 100 mg PO BID x 7 days
• Fluoroquinolones – avoid as first-line if possible
  • Ciprofloxacin 250 mg BID x 3 days

• • Levofloxacin 250 mg BID x 3 days

• • Norfloxacin 400 mg BID x 3 days
  • Gatifloxacin 200 mg once daily x 3 days
• Microbial prevention of recurrent UTI
  • Patient can take antimicrobial medications above, using a once-daily regimen

• • If cystitis is associated with sexual activity, consider postcoital prophylaxis
    • Take single dose of antimicrobial medication after sexual intercourse

• • Continue for 6-12 months and reassess

Note: FDA (endorsed in ACOG Practice Advisory) recommends the following

FDA has approved label changes that reserve the use of fluoroquinolone antibacterial medicines when treating acute bacterial sinusitis (ABS), acute bacterial exacerbation of chronic bronchitis (ABECB), and uncomplicated urinary tract infections (UTI) for patients who do not have alternative treatment options.

SYNOPSIS:

UTI is the most common infection encountered in the outpatient setting. By age 32, half of all women will have had at least one UTI. Recurrence rates are over 25%. Fluoroquinolones are effective, but the recommendation is to avoid as a first-line medication to prevent future resistance and maintain these medications as a second-line treatment when needed.

KEY POINTS:

• Risk factors include
  • Sexual intercourse | Use of spermacides and diaphragm | Previous UTI | New sexual partner | Increasing parity | Diabetes | Obesity | Kidney stones | indwelling catheter
  • With increasing age, consider vaginal atrophy, pelvic organ prolapse and bladder retention

• No association between
  • Pre/ postcoital voiding | Daily beverage consumption | Frequency of urination | Delayed urination | Wiping patterns | Tampon use | Douching | Hot tub use | Type of underwear

• Consider formal urologic evaluation for women with
  • Persistent hematuria | Multiple early recurrences of cystitis with the same bacteria

• Patients with pyelonephritis with severe/worsening illness or persistent fever 48-72 hours after initiation of antibiotics
  • Image to evaluate for stone, abscess or obstruction
• Treatment of uncomplicated cystitis should take in to consideration antimicrobial resistance patterns
  • Resistance rates higher than 15 to 20% will require a change in antibiotic class
  • Beta-lactams such as cephalosporins and amoxicillin are less effective due to increasing resistance
• Nonantimicrobial prevention of recurrent UTI
  • Change spermicides or consider other birth control option | Topical estrogen if menopausal (local may be more beneficial than oral)

• Note: Do not screen or treat asymptomatic bacteriuria in nonpregnant, premenopausal women

Learn More – Primary Sources:

ACOG Practice Bulletin 91: Treatment of Urinary Tract Infections in Nonpregnant Women

ACOG Committee Opinion 717: Sulfonamides, Nitrofurantoin, and Risk of Birth Defects

Screening for Asymptomatic Bacteriuria in Adults

FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects

Practice Advisory: FDA Warning About Fluoroquinolones and Risk of Aortic Ruptures or Tears

Related ObG Topics:

ACOG and AUGS Guidance: Asymptomatic Microscopic Hematuria in Women

ACOG Guidance on Use of Sulfonamides and Nitrofurantoin for UTIs in the First Trimester

Do Cranberries Decrease Risk of UTIs?

FDA Fluoroquinolone Warning Including Use for UTI Management