Acute Cystitis


Article Author:
Vasimahmed Lala


Article Editor:
David Minter


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/1/2019 1:37:44 PM

Introduction

A urinary tract infection (UTI) is defined as significant bacteriuria in the setting of symptoms of cystitis or pyelonephritis. It is pathogenic inflammation of the upper or lower urinary tract. Women are more commonly afflicted with UTIs and caused by common pathogens such as Escherichia coli (86%) and Staphylococcus saprophyticus (4%). Many women know the symptoms of cystitis which include frequent trips to the bathroom and a stinging and burning sensation when passing urine. A diagnosis of uncomplicated cystitis may be made by history findings, on physical examination, as well as with urinalysis (UA). The severity of the disease can range widely and can result in hospital admission or outpatient treatment.[1][2][3][4]

Etiology

Most UTIs in females are acute uncomplicated cystitis caused by Escherichia coli (86%), Staphylococcus saprophyticus (4%), Klebsiella species (3%), Proteus species (3%), Enterobacter species (1.4%), Citrobacter species (0.8%), or Enterococcus species (0.5%). Urethral catheterization accounts for 80% of nosocomial UTIs; 5% to 10% are related to genitourinary manipulation. Sexual intercourse results in an increased risk, as does use of a diaphragm or spermicide.[5][6]

Epidemiology

Urinary tract infections (UTI) are the most common bacterial infection in women. About 40% of women experiencing a UTI at some point in their lives. The abundance of this disease results in eight million emergency or clinic visits, 100,000 hospital admissions, and annually, $1.6 billion in healthcare costs. Within a year of infection, 27% to 46% of women will have another UTI.

Pathophysiology

Bacterial invasion of the urothelium of the bladder from bacteria migrating from the rectum as well as colonized bacteria from the perineum and vagina. Age is an important factor as estrogen diminishes with age, and pH increases, thus promoting colonization of with gram-negative enteric organisms such as E. coli.

History and Physical

A history is the most important tool for diagnosis of acute uncomplicated cystitis, and it should be supported by a focused examination and urinalysis. It also is important to rule out a more serious, complicated UTI. The new onset of frequency and dysuria, with the absence of vaginal discharge, has a positive predictive value of 90% of UTI.[7][8][9][10]

Sign/Symptoms

  • Cystitis: Frequency, dysuria, urgency, suprapubic pain, cloudy urine, hematuria, nausea, vomiting, and fever
  • Pyelonephritis: Similar symptoms of cystitis but usually will have flank pain, fever, and other systemic symptoms
  • Elderly: Apart from a typical presentation they tend to have altered mental status, lethargy, and generalized weakness.

Cystis can be either complicated or uncomplicated, and the workup, as well as treatment, is guided by identifying which category the patient falls into.

Uncomplicated:  Absence of anatomic or functional abnormalities

Complicated: Anatomical or systemic factors that increase the chance of infection like male gender, diabetes, immunosuppression, polycystic kidney, hospital-acquired, bladder outflow obstruction (prostate hypertrophy, urethral stricture), neuropathic bladder (multiple sclerosis, diabetes mellitus), catheterization or ureter stent, ureterolithiasis, genitourinary surgery or malignancy, vesicoureteral reflux

Physical Exam

A physical examination with acute uncomplicated cystitis is typically normal except in 10% to 20% of women with suprapubic tenderness. Acute pyelonephritis may be suspected if the patient is ill-appearing and seems uncomfortable, particularly if she has a concomitant fever, tachycardia, or costovertebral angle tenderness.

Self Diagnosis and Diagnosis by Telephone

Two recent studies suggest that women who self-diagnose a UTI may be treated safely via telephone management. Women who are treated with acute uncomplicated cystitis previously are usually accurate in determining when they are having another episode.

Evaluation

The convenience and cost-effectiveness of a urine dipstick test make it a common diagnostic tool. It is an appropriate alternative to urinalysis and urine microscopy in the diagnoses acute uncomplicated cystitis. Nitrite and leukocyte esterase are the most accurate indicators of acute uncomplicated cystitis in symptomatic women. 

Urinalysis with microscopy: Ideally mid-steam catch or catheter oriented to avoid contamination. However, at least two studies have shown no significant difference in contaminated or unreliable results in specimens collected either with and without preliminary cleansing.

Nitrites: Bacteria reduction of nitrate to nitrite; typically by gram-negative organisms. Under normal circumstance, urine will have no nitrites. False positives can result from air exposure, and false negative can be the result of the non-nitrite producing organism,  low nitrate diet (decreased vegetables), vitamin C, concentrated urine and low pH.

  • Sensitivity (19% to 48%) and specificity (92% to 100%)

Leukocyte Esterase: Presence of intact or broken down neutrophils. False negatives can be the result of an early infection, vitamin C, concentrated urine, ketonuria, and proteinuria. False positives can be caused by contamination of the urine by skin flora

  • Sensitivity (62% to 98%) and  specificity (55% to 96%)

Pyuria: more than five white blood cell count (WBC) per HPF = Sensitivity (90% to 96%) and specificity (47% to 50%)

WBC Casts: coagulum of Tamm Horsfall mucoprotein and leukocytes from renal tubular lumen which can indicate pyelonephritis

  • Other causes: glomerulonephritis, interstitial nephritis

Bacteria: For clean-catch urine should have colony count more than 100,000 CFU/mL for a single organism. 20% to 40% of women presenting with cystitis have 100-10,000 CFU/mL

Urine culture: Not needed in simple cystitis. Indication for culture is complicated infections, pyelonephritis, and prior antimicrobial treatment. Routine posttreatment urinalysis or urine cultures in asymptomatic patients are not necessary

Imaging: Not needed in routine cases. Ultrasound can evaluate for hydronephrosis or abscess. CT can help you evaluate for kidney stones, hydronephrosis, emphysematous changes, and abscess.

Treatment / Management

There are many things to consider when treating cystitis. The choice between agents should be individualized and depends on the duration of treatment as well as the possible organism involved. According to guidelines, there is no single, best agent to treat acute uncomplicated cystitis. Choosing an antibiotic depends on its effectiveness, the risk of adverse effects, resistance rates, and propensity to cause collateral damage; furthermore, physicians should consider cost, availability, and patient factors, such as allergy history. On average, patients will experience symptom relief within 36 hours of the beginning treatment. 

Uncomplicated Cystitis

  • Nitrofurantoin (Macrobid) 100 mg by mouth twice a day for 5 days
  • Trimethoprim-sulfamethoxazole 160 mg/800 mg twice a day for 3 days
  • Ciprofloxacin 250 mg twice a day or levofloxacin 250 mg twice a day for 3 days
  • Alternatives are B-lactams such as amoxicillin-clavulanate 500/125 mg twice a day for seven days or Cephalexin 250 mg four times per day for 3 to 7 days.

Complicated Cystitis

There is no absolute guideline for treatment typically requires a longer duration (about seven days). Recommended treatments are listed below.

Nonpregnant women

  • Ciprofloxacin 500 mg by mouth twice a day 7 to 10 days
  • Nitrofurantoin Monohydrate/microcrystals 100 mg mouth twice a day for 7 days

Pregnant women

A shorter course of antibiotic therapy is preferred in pregnant patients. Fluoroquinolones are contraindicated during pregnancy. Nitrofurantoin is contraindicated in a pregnant patient at term, during labor, and delivery. 

  • Amoxicillin-clavulanate 500 mg/12 mg by mouth twice a day for 7 days 
  • Keflex 500 mg by mouth four times a day for 3 to 5 days
  • Cefpodoxime 100 mg twice a day for 5 to 7 days.

Men

Acute cystitis is always recognized as complicated. Men with cystitis who do not have signs or symptoms of prostatitis can be treated with the following regiments.

  • Ciprofloxacin 500 mg by mouth twice a day for 7 days
  • Levofloxacin 750 mg by mouth four times a day for 7 days
  • Macrobid 100 mg by mouth twice a day for 7 days.

Pearls and Other Issues

Antibiotic Resistance

First-line therapy for acute uncomplicated cystitis should not include beta-lactam antibiotics. This is because widespread E. Coli resistance rates are above 20%. Fluoroquinolone resistance is below 10% in North America and Europe. Treatment should be individualized based on local resistance.

Possible indications for Admission

  • Failed outpatient treatment
  • Intractable nausea and vomiting
  • Intractable pain
  • Complications: sepsis/shock, acute kidney injury, abscess formation, emphysematous changes.
  • Inability to care for self (encephalopathy, weakness).

Enhancing Healthcare Team Outcomes

Acute cystitis is often managed by an interprofessional team that includes a primary care provider, nurse practitioner, internist, urologist, and a nephrologist. It is important to understand that most simple cases of cystitis resolve quickly with treatment, but if there is a persistence of symptoms, admission is recommended.

There are many things to consider when treating cystitis. The choice between agents should be individualized and depends on the duration of treatment as well as the possible organism involved. According to guidelines, there is no single, best agent to treat acute uncomplicated cystitis. Choosing an antibiotic depends on its effectiveness, the risk of adverse effects, resistance rates, and propensity to cause collateral damage; furthermore, physicians should consider cost, availability, and patient factors, such as allergy history. On average, patients will experience symptom relief within 36 hours of the beginning treatment. (Level V)


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Acute Cystitis - Questions

Take a quiz of the questions on this article.

Take Quiz
A 32-year-old female presents with symptoms consistent with acute uncomplicated cystitis. Urinalysis reveals pyuria. Which of the following is the most appropriate next step?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true regarding acute cystitis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following symptoms is typical of a patient presenting with acute cystitis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the most common pathophysiologic mechanism by which acute cystitis occurs?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the best way to relieve the lower pelvic pain due to cystitis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Acute cystitis is much more common in females compared to males. Which of the following explanations likely places females at increased risk?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient presents with uncomplicated acute cystitis. Which of the following in the history would necessitate urine culture and sensitivity testing?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 24-year-old female presents complaining of dysuria and urinary urgency. She has no significant past medical problems other than a severe sulfa allergy. Which of the following antibiotics is most appropriate for empiric treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
An 86-year-old woman complains of urinary incontinence with lower abdominal discomfort for two weeks. She reports no dysuria, fever, or back pain. Medical history is significant for controlled type 2 diabetes mellitus and allergic reaction to sulfa drugs, which cause a generalized rash. On physical examination, temperature is 98.6 F, blood pressure is 145/92 mmHg, pulse rate is 74/min, and respiration rate is 17/min. Mild suprapubic tenderness but no costovertebral angle tenderness. The remainder of the examination is within normal limits. Urine dipstick is positive for leukocyte esterase and nitrites. Which of the following is the most appropriate management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old female presents to her primary care provider complaining of lower abdominal pain, as well as urinary urgency and dysuria for the past two days. She denies any fevers, chills or other systemic symptoms. A urinalysis was positive for infection and she was prescribed antibiotics. Which bacteria is the most likely cause of her infection?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Acute Cystitis - References

References

Hanlon JT,Perera S,Drinka PJ,Crnich CJ,Schweon SJ,Klein-Fedyshin M,Wessel CB,Saracco S,Anderson G,Mulligan M,Nace DA, The IOU Consensus Recommendations for Empirical Therapy of Cystitis in Nursing Home Residents. Journal of the American Geriatrics Society. 2018 Dec 24;     [PubMed]
Rank EL,Lodise T,Avery L,Bankert E,Dobson E,Dumyati G,Hassett S,Keller M,Pearsall M,Lubowski T,Carreno JJ, Antimicrobial Susceptibility Trends Observed in Urinary Pathogens Obtained From New York State. Open forum infectious diseases. 2018 Nov;     [PubMed]
Cruz J,Figueiredo F,Matos AP,Duarte S,Guerra A,Ramalho M, Infectious and Inflammatory Diseases of the Urinary Tract: Role of MR Imaging. Magnetic resonance imaging clinics of North America. 2019 Feb;     [PubMed]
Nace DA,Perera SK,Hanlon JT,Saracco S,Anderson G,Schweon SJ,Klein-Fedyshin M,Wessel CB,Mulligan M,Drinka PJ,Crnich CJ, The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents. Journal of the American Medical Directors Association. 2018 Sep;     [PubMed]
Leung AKC,Wong AHC,Leung AAM,Hon KL, Urinary Tract Infection in Children. Recent patents on inflammation     [PubMed]
May M,Schostak M,Lebentrau S, Guidelines for patients with acute uncomplicated cystitis may not be a paper tiger: a call for its implementation in clinical routine. International urogynecology journal. 2018 Dec 18;     [PubMed]
Kranz J,Schmidt S,Lebert C,Schneidewind L,Mandraka F,Kunze M,Helbig S,Vahlensieck W,Naber K,Schmiemann G,Wagenlehner FM, The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients. Part II: Therapy and Prevention. Urologia internationalis. 2018;     [PubMed]
Korbel L,Howell M,Spencer JD, The clinical diagnosis and management of urinary tract infections in children and adolescents. Paediatrics and international child health. 2017 Nov;     [PubMed]
Gregory DS,Wu V,Tuladhar P, The Pregnant Patient: Managing Common Acute Medical Problems. American family physician. 2018 Nov 1;     [PubMed]
Bollestad M,Vik I,Grude N,Lindbæk M, Predictors of Symptom Duration and Bacteriuria in Uncomplicated Urinary Tract Infection. Scandinavian journal of primary health care. 2018 Dec;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatrics-Medical Student. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatrics-Medical Student, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatrics-Medical Student, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatrics-Medical Student. When it is time for the Pediatrics-Medical Student board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatrics-Medical Student.