Uncomplicated Cystitis: When to Culture, How to Treat and Recommended Prevention Strategies

CLINICAL ACTIONS:

Acute uncomplicated cystitis is often readily recognized by patients as a routine bladder infection.  Uncomplicated cystitis rarely progresses to pyelonephritis 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: The following recommendations apply to nonpregnant women | There has been concern regarding the use of nitrofurantoin and sulfonamides in the first trimester due to possible risk for birth defects

• First-line therapy 
  • Trimethoprim-Sulfamethoxazole (TMP-SMX) 160-800 mg PO BID x 3 days
  • Fosfomycin 3 gm PO single dose
  • Nitrofurantoin 100 mg PO BID x 5 days
  • Consider beta-lactam for pregnant patients
• Fluoroquinolones: Reserved for situations in which other agents are not appropriate  
  • Ciprofloxacin 250 mg BID x 3 days
  • Levofloxacin 250 mg BID x 3 days

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 spermicides 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 to 72 hours after initiation of antibiotics
  • Image to evaluate for stone, abscess or obstruction
• Treatment of uncomplicated cystitis should take into consideration local 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:

CDC: Adult Outpatient Treatment Recommendations | Antibiotic Use

ACP: Appropriate Use of Short-Course Antibiotics in Common Infections

USPSTF: Screening for Asymptomatic Bacteriuria in Adults

CDC: Improve Fluoroquinolone Prescribing Practices