ESSENTIALS OF DIAGNOSIS
Irritative voiding symptoms.
Patient usually afebrile.
Positive urine culture; blood cultures may also be positive.
Acute cystitis is an infection of the bladder, most commonly due to the coliform bacteria (especially E coli) and occasionally gram-positive bacteria (enterococci). The route of infection is typically ascending from the urethra. Viral cystitis due to adenovirus is sometimes seen in children but is rare in immunocompetent adults. Uncomplicated cystitis in men is rare and implies a pathologic process such as infected stones, prostatitis, or chronic urinary retention requiring further investigation.
Irritative voiding symptoms (frequency, urgency, dysuria) and suprapubic discomfort are common. Women may experience gross hematuria, and symptoms may often appear following sexual intercourse. Physical examination may elicit suprapubic tenderness, but examination is often unremarkable. Systemic toxicity is absent.
Urinalysis shows pyuria, bacteriuria, and varying degrees of hematuria. The degree of pyuria and bacteriuria does not necessarily correlate with the severity of symptoms. Urine culture is positive for the offending organism, but colony counts exceeding 105/mL are not required for the diagnosis. Patients with asymptomatic bacteriuria or colonization are expected to have positive urine cultures but do not require treatment except in pregnant women. Patients with long-term urinary catheters (indwelling urinary [Foley] or suprapubic catheter) or urostomy urinary diversions are expected to be colonized with bacteria, and thus, urinalysis and urine culture are most helpful in directing therapy rather than determining whether symptomatic infection exists.
Because uncomplicated cystitis is rare in men, elucidation of the underlying problem with appropriate investigations, such as abdominal ultrasonography, postvoid residual testing, and cystoscopy, is warranted. Follow-up imaging using CT scanning is warranted if pyelonephritis, recurrent infections, or anatomic abnormalities are suspected.
In women, infectious processes such as vulvovaginitis and pelvic inflammatory disease can usually be distinguished by pelvic examination and urinalysis. In men, urethritis and prostatitis may be distinguished by physical examination (urethral discharge or prostatic tenderness).
Noninfectious causes of cystitis-like symptoms include pelvic irradiation, chemotherapy (cyclophosphamide), bladder carcinoma, interstitial cystitis, voiding dysfunction disorders, and psychosomatic disorders.
The risk of developing a urinary tract infection can be reduced by drinking plenty of fluid and completely emptying the bladder frequently. Women in whom urinary tract infections tend to develop after intercourse should be advised to void before, and especially after intercourse, and may benefit from a postcoital single-dose of antibiotic. Postmenopausal women with recurrent urinary tract infections (three or more episodes per year) may benefit from a topical estrogen cream. Daily cranberry tablets may reduce the risk of cystitis, though the data are conflicting. Prophylactic antibiotics are generally discouraged. Prior to institution of antibiotic prophylaxis, a thorough urologic evaluation is warranted to exclude any anatomic abnormality (eg, stones, reflux, fistula). An initial course of 6 to 12 months of prophylactic antibiotics can be offered. The benefits of prophylactic antibiotics should be weighed against the risks of developing bacterial resistance.
The risk of acquiring a catheter-associated urinary tract infection in hospitalized patients can be minimized by using indwelling catheters only when necessary, implementing systems to ensure removal of catheters when no longer needed, using antimicrobial catheters in high-risk patients, using external collection devices in select men, identifying significant postvoid residuals by ultrasound, maintaining proper insertion techniques, and utilizing alternatives such as intermittent catheterization.
Uncomplicated cystitis in women can be treated with short-term antimicrobial therapy, which consists of single-dose therapy or 1–7 days of therapy. Fosfomycin, nitrofurantoin, and trimethoprim-sulfamethoxazole are the medications of choice for uncomplicated cystitis (Table 23–1). The US Food and Drug Administration (FDA) advises restricting fluoroquinolone use for uncomplicated infections. Local patterns of bacterial resistance should be consulted to identify best treatment options. Some antibiotics may be ineffective because of the emergence of resistant organisms. A review of the literature proposed that acute uncomplicated cystitis in women can be diagnosed without office evaluation or urine culture, and that appropriate first-line therapies include trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), nitrofurantoin (100 mg twice daily for 5–7 days), or fosfomycin trometamol (3 g single dose). In men, uncomplicated urinary tract infection is rare; thus, the duration of antibiotic therapy depends on the underlying etiology. Hot sitz baths or urinary analgesics (phenazopyridine, 200 mg orally three times daily) may provide symptomatic relief. Postmenopausal women with recurrent cystitis can be treated with vaginal estrogen cream 0.5 g nightly for 2 weeks and then twice weekly thereafter.
Table 23–1.Empiric therapy for urinary tract infections. ||Download (.pdf) Table 23–1. Empiric therapy for urinary tract infections.
|Diagnosis ||Antibiotic ||Route ||Duration ||Cost per Duration Noted1 |
|Acute cystitisa || || || || |
| ||First-line: || || || |
| || Trimethoprim-sulfamethoxazole, 160/800 mg, (one DS tablet) every 12 hours2 ||Oral ||3 days ||$2.25 |
| || Nitrofurantoin (macrocrystals), 100 mg every 12 hours ||Oral ||5 days ||$31.35 |
| || Fosfomycin, 3 g packet once ||Oral ||1 day ||$109.52 |
| ||Second-line: || || || |
| || Ciprofloxacin, 250 mg every 12 hours3 ||Oral ||3 days ||$25.28 |
| || Levofloxacin, 250–500 mg daily3 ||Oral ||3 days ||$46.80 |
| ||Alternative agents: || || || |
| || Cephalexin, 500 mg every 6–12 hours ||Oral ||7 days ||$33.88 |
| || Amoxicillin/clavulanate, 500/125 mg every 12 hours ||Oral ||3 days ||$22.00 |
| || Cefpodoxime, 100 mg every 12 hours ||Oral ||3 days ||$30.66 |
|Acute pyelonephritisa || || || || |
| ||Hospitalized: || || || |
| || Ampicillin, 1 g every 6 hours, plus gentamicin, 1 mg/kg every 8 hours ||Intravenous ||14 days ||$270.48, not including intravenous supplies |
| || Ceftriaxone, 1 g daily ||Intravenous ||14 days ||$25.20 |
| || Ciprofloxacin, 400 mg every 12 hours ||Intravenous ||14 days ||$99.12 |
|Acute pyelonephritis (cont.) || || || || |
| ||Non-hospitalized: || || || |
| || Initial intravenous dose:4 || || || |
| || Ceftriaxone, 1 g ||Intravenous ||Once ||$1.80 |
| || Ciprofloxacin, 400 mg ||Intravenous ||Once ||$3.54 |
| || Gentamicin, 5 mg/kg ||Intravenous ||Once ||$5.00 |
| || Followed by one of these oral regimens: || || || |
| || Ciprofloxacin, 500 mg every 12 hours2 ||Oral ||7 days ||$4.90 |
| || Levofloxacin, 750 mg daily ||Oral ||5 days ||$123.05 |
| || Trimethoprim-sulfamethoxazole, 160/800 mg (one DS tablet) every 12 hours5 ||Oral ||14 days ||$10.44 |
|Acute bacterial prostatitisb || Hospitalized: || || || |
| || Ampicillin, 2 g every 6 hours, plus gentamicin, 1.5 mg/kg every 8 hours ||Intravenous ||Until afebrile ||$37.20/day, not including intravenous supplies |
| ||Followed by one of these outpatient oral regimens: || || || |
| || Trimethoprim-sulfamethoxazole, 160/800 mg (one DS tablet) every 12 hours5 ||Oral ||3 weeks ||$15.75/3 weeks |
| || Ciprofloxacin, 250–500 mg every 12 hours ||Oral ||3 weeks ||$14.70/3 weeks |
|Chronic bacterial prostatitisb || First-line: || || || |
| Ciprofloxacin, 500 mg every 12 hours ||Oral ||1–3 months ||$21.00/month |
| || Levofloxacin, 750 mg daily ||Oral ||28 days ||$689.08 |
| ||Second-line: || || || |
| || Doxycycline, 100 mg twice daily ||Oral ||4–12 weeks ||$127.80/month |
| || Azithromycin, 500 mg daily ||Oral ||4–12 weeks ||$105.60/month |
| || Clarithromycin, 500 mg daily ||Oral ||4–12 weeks ||$117.00/month |
|Acute epididymitisc || || || || |
| Sexually transmitted (under age 35) || |
Ceftriaxone, 250 mg as single dose, plus
Doxycycline, 100 mg every 12 hours
$85.20 (10 days)
| Sexually transmitted in men who practice insertive anal sex || |
Ceftriaxone, 250 mg as single dose plus
Levofloxacin, 500 mg daily or
Ofloxacin, 300 mg every 12 hours
$156.00 (10 days)
$113.80 (10 days)
| Non–sexually trans- mitted, usually enteric organisms (over age 35) || |
Levofloxacin, 500 mg daily
Ofloxacin, 300 mg every 12 hours
$156.00 (10 days)
$113.80 (10 days)
Infections typically respond rapidly to therapy, and failure to respond suggests resistance to the selected medication or anatomic abnormalities requiring further investigation.
Suspicion or radiographic evidence of anatomic abnormality.
Evidence of urolithiasis.
Recurrent cystitis due to bacterial persistence.
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