Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Cystitis in Females Treatment & Management

  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Aug 19, 2015
 

Approach Considerations

Appropriate antibiotic treatment leads to significantly higher symptomatic and bacteriologic cure rates and better prevention of reinfection in women with uncomplicated cystitis.[24] Unfortunately, treatment also selects for antibiotic resistance in uropathogens and commensal bacteria and has adverse effects on the gut and vaginal flora.[25]

Consequently, evolving practice seeks to achieve good symptom control for uncomplicated acute cystitis while reducing antibiotic use. For example, European practice increasingly includes the option of offering a 48-hour delayed antibiotic prescription to be used at the patient's discretion.[26]

The first-choice agents for treatment of uncomplicated acute cystitis in women include nitrofurantoin monohydrate/macrocrystals, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin. Beta-lactam antibiotics may be used when other recommended agents cannot be used.[1, 2] Fosfomycin and nitrofurantoin monohydrate/macrocrystals should be avoided in patients with possible early pyelonephritis.[1] Fluoroquinolones are typically reserved for complicated cystitis.

Empiric antibiotic selection is determined in part by local resistance patterns. In addition, clinicians may wish to limit use of TMP-SMX in order to reduce the emergence of resistant organisms.

Resistance to TMP-SMX has been associated with concomitant resistance to other antibiotics. Because of the importance of maintaining the effectiveness of TMP-SMX for treatment of serious infections, German national guidelines no longer recommend this agent as first-line empiric treatment for uncomplicated cystitis.[2]

On average, women with cystitis who receive effective antibiotic treatment experience severe symptoms for somewhat longer than 3 days.[12] Complete resolution of symptoms may require approximately 6 days. Features that have been associated with a more prolonged course include a history of somatization, previous cystitis, urinary frequency, and more severe symptoms at baseline.[12] Patients who respond to antibiotics do not require follow-up urine cultures.

Without treatment, 25-42% of uncomplicated acute cystitis cases in women will resolve spontaneously.[24] Even without effective treatment, the likelihood that uncomplicated acute cystitis will progress to pyelonephritis is only around 2%.[27]

German investigators reported that symptomatic treatment with ibuprofen (400 mg 3 times daily) did not prove to be inferior to antibiotic treatment with ciprofloxacin.[28] This randomized, controlled pilot trial in 79 women with uncomplicated acute cystitis found no significant difference in symptom resolution between the 2 groups. A notable but statistically insignificant difference was that 33.3% of patients in the ibuprofen group and 18% in the ciprofloxacin group required secondary antibiotic treatment.

Patient disposition

With few exceptions, the vast majority of women with urinary tract infection (UTI) present on an ambulatory basis and can be treated as outpatients. Exceptions include immunocompromised or elderly patients who have a UTI manifesting as a sepsis syndrome with circulatory insufficiency. In this situation, mental status changes (eg, confusion) or profound weakness may prompt paramedical transport to the hospital. Patients with hypotension, tachycardia, and delayed capillary refill require intravenous (IV) fluid resuscitation in the field.

Hospital admission may be indicated for some patients with complicated UTI. Complicating factors include the following:

  • Structural abnormalities (eg, calculi, tract anomalies, indwelling catheter, obstruction)
  • Metabolic disease (eg, diabetes, renal insufficiency)
  • Impaired host defenses (eg, HIV, current chemotherapy, underlying active cancer)

Adequate fluid resuscitation restores effective circulating volume and generous urinary volumes. Antipyretic pain medications may be administered, as appropriate.

Next

Uncomplicated Cystitis in Nonpregnant Patients

Uncomplicated cystitis occurs in patients who have a normal, unobstructed genitourinary tract; who have no history of recent instrumentation; and whose symptoms are confined to the lower urinary tract. Uncomplicated cystitis is most common in young, sexually active women. Patients usually present with dysuria, urinary frequency, urinary urgency, and/or suprapubic pain. Treatment regimens for uncomplicated cystitis in nonpregnant women are provided in Table 1, below.

Table 1. Treatment Regimens for Uncomplicated Cystitis in Nonpregnant Women[1] (Open Table in a new window)

First-line therapy
  • trimethoprim/sulfamethoxazole * 160 mg/800 mg (Bactrim DS, Septra DS) 1 tablet PO BID for 3d (use when bacterial resistance is < 20% and patient has no allergy) or
  • nitrofurantoin monohydrate/macrocrystals (Macrobid) 100 mg PO BID for 5-7d or
  • nitrofurantoin macrocrystals (Macrodantin) 50-100 mg PO QID for 7d or
  • fosfomycin (Monurol) 3 g PO as a single dose with 3-4 oz of water
Second-line therapy
  • ciprofloxacin (Cipro) 250 mg PO BID for 3d or
  • ciprofloxacin extended release (Cipro XR) 500 mg PO daily for 3d or
  • levofloxacin (Levaquin) 250 mg PO q24h for 3d or
  • ofloxacin 200 mg PO q12h for 3d
Alternative therapy
  • amoxicillin-clavulanate (Augmentin) 500 mg/125 mg PO BID for 3-7d or
  • amoxicillin-clavulanate (Augmentin) 250 mg/125 mg PO TID for 3-7d or
  • cefdinir 300 mg PO BID for 7d or
  • cefaclor 500 mg PO TID for 7d or
  • cefpodoxime 100 mg PO BID for 7d or
  • cefuroxime 250 mg PO BID for 7-10d
*Should generally be avoided in elderly patients because of the risk of affecting renal function.
Previous
Next

Complicated Cystitis in Nonpregnant Women

Complicated cystitis is associated with an underlying condition that increases the risk of therapeutic failure. Some underlying conditions include diabetes, symptoms for 7 days or longer before seeking care, renal failure, functional or anatomic abnormality of the urinary tract, renal transplantation, an indwelling catheter stent, or immunosuppression. Treatment regimens for complicated cystitis in nonpregnant women are provided in Table 2, below.

Table 2. Treatment Regimens for Complicated Cystitis in Nonpregnant Women[15] (Open Table in a new window)

First-line therapy
Oral:



Patients with complicated cystitis who can tolerate oral therapy may be treated with the following options:



  • ciprofloxacin (Cipro) 500 mg PO BID for 7-14d or
  • ciprofloxacin extended release (Cipro XR) 1 g PO daily for 7-14d or
  • levofloxacin (Levaquin) 750 mg PO daily for 5d
Parenteral:



Patients who cannot tolerate oral therapy as outlined above or patients with infection that is suspected to be due to resistant organisms should be treated with parenteral therapy, as follows:



  • ciprofloxacin (Cipro) 400 mg IV q12h for 7-14d or
  • levofloxacin (Levaquin) 750 mg IV daily for 5d or
  • ampicillin 1-2 g IV q6h plus gentamicin 2 mg/kg/dose q8h for 7-14d or
  • piperacillin-tazobactam (Zosyn) 3.375 g IV q6h or
  • doripenem 500 mg (Doribax) IV q8h for 10d or
  • imipenem-cilastatin (Primaxin) 500 mg IV q6h for 7-14d or
  • meropenem (Merrem) 1 g IV q8h for 7-14d
Duration of therapy: shorter courses (7d) are reasonable if patient improves rapidly; longer courses (10-14d) are reasonable if patient has a delayed response or is hospitalized.



Parenteral therapy can be switched to oral therapy once clinical improvement is observed.



Second-line therapy
  • cefepime (Maxipime) 2 g IV q12h for 10d or
  • ceftazidime (Fortaz, Tazicef) 500 mg IV or IM q8-12h for 7-14d
Duration of therapy: shorter courses (7d) are reasonable if patient improves rapidly; longer courses (10-14d) are reasonable if patient has a delayed response or is hospitalized.



Parenteral therapy can be switched to oral therapy once clinical improvement is observed.



Previous
Next

Antimicrobial Therapy

Oral therapy with an antibiotic effective against gram-negative aerobic coliform bacteria, such as E coli, is the principal treatment intervention in patients with lower urinary tract infections.

For women with acute bacterial cystitis who are otherwise healthy and not pregnant, 3 days of therapy with most antimicrobial agents is generally more effective than single-dose therapy and as effective as the same drug administered for a longer duration. Exceptions are nitrofurantoin monohydrate/macrocrystals and beta-lactams as a group. Cystitis in older women or infection caused by Staphylococcus saprophyticus is less responsive to 3 days of therapy; therefore, 7 days of therapy is suggested.

The 2010 Infectious Disease Society of America (IDSA) guidelines for uncomplicated cystitis in nonpregnant patients recommend nitrofurantoin monohydrate/macrocrystals (Macrobid, 100 mg orally twice daily for 5-7 days) or nitrofurantoin macrocrystals (Macrodantin, 50 -100 mg orally 4 times daily for 7 days). Efficacy is comparable to 3 days of trimethoprim-sulfamethoxazole (TMP-SMX).[1]

IDSA guidelines recommend TMP-SMX (160 mg/800 mg [1 double-strength tablet] orally given twice daily for 3 days) as an appropriate choice for treatment of acute uncomplicated cystitis if local resistance rates of uropathogens do not exceed 20% or if the infecting strain is known to be susceptible. TMP-SMX should not be used empirically if the patient has received this agent for treatment of UTI during the previous 3 months.[1]

Nitrofurantoin monohydrate/macrocrystals has the advantage of taking resistance pressure off the much-used quinolone class. In a 2009 analysis by Olson et al, 29.6% of 176 urinary isolates with E coli studied were resistant to TMP-SMX; none was resistant to nitrofurantoin macrocrystals. Resistance to ciprofloxacin was 1.8% in first-time UTIs, versus 11.8% in recurrent UTIs. The authors recommended considering nitrofurantoin as a first-line agent for uncomplicated lower UTIs.[29]

Similarly, a decision and cost analysis by McKinnell et al found that nitrofurantoin minimized cost when the prevalence of fluoroquinolone resistance exceeded 12% or the prevalence of TMP-SMX resistance exceeded 17%.[30] On the basis of efficacy, cost, and low impact on promoting antimicrobial resistance, these researchers recommended that clinicians consider nitrofurantoin as a reasonable alternative to TMP-SMX and fluoroquinolones for first-line therapy for uncomplicated UTIs.

Fosfomycin (a single dose of 3 g with 3-4 oz of water) is also an appropriate choice for therapy, where available, because of minimal resistance and propensity for collateral damage. Fosfomycin is approved by the US Food and Drug Administration (FDA) for single-dose treatment in adult women with uncomplicated UTI caused by Escherichia coli or Enterococcus faecalis.

It has been reported that the efficacy of single-dose fosfomycin is inferior to that of standard short-course regimens.[1] However, a recent meta-analysis of 27 trials found no difference in efficacy between fosfomycin and other antibiotics for treatment of cystitis and found that fosfomycin was associated with significantly fewer adverse reactions in pregnant women.[31]

Fluoroquinolones (eg, ofloxacin, ciprofloxacin, levofloxacin) are highly effective in UTIs, but these agents have a propensity for causing collateral damage and should be reserved for important uses other than acute uncomplicated cystitis.[1] IDSA guidelines recommend that fluoroquinolones be used as second-line agents for acute uncomplicated cystitis and as first-line oral therapy for complicated cystitis.

According to the IDSA guidelines, beta-lactam agents (eg, amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) in 3–7-day regimens are appropriate second-line choices when other recommended agents cannot be used. The IDSA advises against using amoxicillin or ampicillin for empiric treatment, because these agents have relatively poor efficacy and high rates of resistance.[1]

Previous
Next

Adjunctive Therapy

Patients with intense dysuria may obtain symptomatic relief from a bladder analgesic, such as phenazopyridine, to be used for 1-2 days. Do not prescribe phenazopyridine if the patient has a sulfa allergy. Avoid long-term use, as this agent may mask symptoms of therapeutic failure or recurrence. Many authors advise stressing the intake of plenty of fluids to promote a dilute urine flow.

Previous
Next

Fungal Infection

In catheterized patients, removal of the catheter is essential for clearance of funguria. If the catheter is still needed, replace it (preferably a day later).

Treatment options vary from topical treatment to systemic therapy. A regimen of amphotericin-B bladder washes for 7 days provides a prompt but nonsustained response. It does not treat systemic mycoses and is inconvenient to administer. Amphotericin B, 0.3 mg/kg IV for 1 dose, is an option that provides a more sustained and systemic response.

Fluconazole 200 mg orally, followed on subsequent days by 100 mg orally once a day for 4-7 days, is a simpler option. This drug is effective against azole-responsive Candida organisms. Generally, azole resistance is observed only in C krusei and C glabrata. Fluconazole provides a good long-term effect but takes a few days to clear the urine.

Previous
Next

Treatment in Patients with Spinal Cord Injury

Once a urethral catheter is in place, the daily incidence of bacteriuria is 3-10%. Antibiotics should be reserved for patients with clear signs and symptoms of UTI. In these patients, suprapubic aspiration of the bladder is the criterion standard for diagnosing a UTI, although it is not performed often in clinical practice.

Oral fluoroquinolones are the drugs of choice for empiric treatment of acute UTIs. However, these drugs have a propensity for collateral damage and should be reserved for important uses other than acute cystitis.

For more information on this topic, see the Medscape Reference article Urinary Tract Infections in Patients with Spinal Cord Injury.

Previous
Next

Pregnant Patients

The physiologic changes associated with pregnancy increase the risk of serious infectious complications from symptomatic and asymptomatic urinary tract infections even in healthy pregnant women. Consequently, treatment is indicated for pregnant women with asymptomatic bacteriuria, as well as for those with symptomatic UTIs; antibiotic selection may differ, and regimens are typically more prolonged.

For more information, see the Medscape Reference topic Urinary Tract Infections in Pregnancy.

Previous
Next

Renal Transplantation Patients

Treatment of UTIs in renal transplant patients is preferably with a fluoroquinolone. TMP-SMX poses the risk of inducing renal failure in the transplanted kidney and consequently should be avoided unless the patient’s creatinine clearance is normal.

Asymptomatic bacteriuria should be treated for 10 days. Parenteral antibiotics should be used for severe infections. The duration of antibiotics for severe infections is 4-6 weeks.

Previous
Next

Asymptomatic Bacteriuria

In most patient populations, asymptomatic bacteriuria has not been shown to be harmful. Furthermore, although persons with bacteriuria are at increased risk of symptomatic urinary tractions, treatment of asymptomatic bacteriuria does not decrease the frequency of symptomatic infections or improve other outcomes. Consequently, screening for or treatment of asymptomatic bacteriuria is not appropriate and should be discouraged.[32]

Asymptomatic bacteriuria in women should be treated only in pregnant patients, in patients undergoing a urologic procedure that may produce mucosal bleeding, and in the significantly immunosuppressed (eg, renal transplantation patients). It should not be treated in diabetic persons, elderly individuals, and patients with indwelling catheters. Diabetic woman have a high rate of asymptomatic bacteriuria with nonpathogenic strains, which can persist for long periods without progressing to infection.[33]

For a full discussion of this topic, see the Medscape Reference article Asymptomatic Bacteriuria.

Previous
Next

Diet

Hydration to accentuate unidirectional clearance of bacteriuria is recommended, especially if an obstruction was relieved recently. Drinking cranberry juice (10 oz/day) or taking cranberry tablets may offer some benefit in reducing recurrent UTI and does not appear to be harmful.[34, 35]

Cranberries contain type A proanthocyanidins. This compound and its urinary metabolites interfere with the adhesiveness of uropathogenic bacteria to the bladder epithelium.[36] Their effect is not as significant as antibiotics, but they do not induce bacterial resistance. Because of their variable intestinal absorption, it is difficult to design a valid study comparing them head-to-head with antimicrobials.[34]

Previous
Next

Consultations

Urologic consultation is essential in patients with UTIs complicated by obstruction, renal cysts, perinephric abscess, renal carbuncle, or unknown renal masses. Other consultations depend on the patient's underlying state of health and may include an obstetrician, gynecologist, endocrinologist, nephrologist, neurologist, or neurosurgeon. In patients who present to the emergency department, consultation with the patient's primary care provider is suggested.

In the patient with a complicated UTI, coverage for unusual or multiple antibiotic–resistant organisms (eg, Pseudomonas aeruginosa) must be considered. An infectious disease consultation may be helpful in selecting the appropriate antimicrobial agent. Infectious disease input is essential for immunocompromised patients and those infected with unusual or resistant pathogens. A pharmacokinetics consultation is suggested when using aminoglycosides.

Previous
Next

Prevention and Long-Term Monitoring

Prophylactic measures are indicated for patients with any of the following:

  • Recurrent UTIs
  • Spinal cord injury
  • Urinary catheters
  • Renal transplants

Sexually active women may attempt voiding immediately after intercourse to lessen the risk of coitus-related introduction of bacteria into the bladder. Some authors recommend large urinary flow volumes as a measure that will reduce the risk of UTI.

Prophylactic regimens for women with frequent recurrent UTIs include postcoital or continuous antibiotics. Women with fewer than 3 UTIs per year may benefit from self-initiated antibiotic therapy. For more information, see the Medscape Reference topic Prevention of Urinary Tract Infections.

In a 12-month randomized study of 28 women with recurrent bacterial cystitis, treatment with intravesical hyaluronic acid and chondroitin sulfate significantly reduced cystitis recurrence and improved urinary symptoms, quality of life, and cystometric capacity, as compared with antibiotic prophylaxis. Intravesical treatment was given once weekly for 4 weeks, then once every 2 weeks twice more. Antibiotic prophylaxis consisted of sulfamethoxazole and trimethoprim once weekly for 6 weeks.[37]

Previous
 
 
Contributor Information and Disclosures
Author

John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Jeffrey M Tessier, MD Assistant Professor, Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine

Jeffrey M Tessier, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Mary F Bavaro, MD Fellowship Director, Division of Infectious Disease, Navy Medical Center, San Diego

Mary F Bavaro, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

David S Howes, MD Professor of Medicine and Pediatrics, Section Chief and Emergency Medicine Residency Program Director, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Elicia S Kennedy, MD Clinical Assistant Professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences

Elicia S Kennedy, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Klaus-Dieter Lessnau, MD, FCCP Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Sepracor None None

Allison M Loynd, DO Resident Physician, Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Receiving Hospital

Allison M Loynd, DO is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Adam J Rosh, MD Assistant Professor, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Joseph A Salomone III, MD Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

References
  1. [Guideline] Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar. 52(5):e103-20. [Medline]. [Full Text].

  2. [Guideline] Wagenlehner FM, Schmiemann G, Hoyme U, Fünfstück R, Hummers-Pradier E, Kaase M, et al. [National S3 guideline on uncomplicated urinary tract infection: recommendations for treatment and management of uncomplicated community-acquired bacterial urinary tract infections in adult patients]. Urologe A. 2011 Feb. 50(2):153-69. [Medline]. [Full Text].

  3. Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008 Mar. 22(1):73-87, vi. [Medline].

  4. Little P, Turner S, Rumsby K, Warner G, Moore M, Lowes JA, et al. Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study. Health Technol Assess. 2009 Mar. 13(19):iii-iv, ix-xi, 1-73. [Medline].

  5. Lane DR, Takhar SS. Diagnosis and management of urinary tract infection and pyelonephritis. Emerg Med Clin North Am. 2011 Aug. 29(3):539-52. [Medline].

  6. Czaja CA, Stamm WE, Stapleton AE, et al. Prospective cohort study of microbial and inflammatory events immediately preceding Escherichia coli recurrent urinary tract infection in women. J Infect Dis. 2009 Aug 15. 200(4):528-36. [Medline].

  7. Kanj SS, Kanafani ZA. Current concepts in antimicrobial therapy against resistant gram-negative organisms: extended-spectrum beta-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa. Mayo Clin Proc. 2011 Mar. 86(3):250-9. [Medline]. [Full Text].

  8. [Guideline] Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010 Mar 1. 50(5):625-63. [Medline]. [Full Text].

  9. Tiemstra JD, Chico PD, Pela E. Genitourinary infections after a routine pelvic exam. J Am Board Fam Med. 2011 May-Jun. 24(3):296-303. [Medline].

  10. Hsiao CJ, Cherry DK, Beatty PC, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2007 summary. Natl Health Stat Report. 2010 Nov 3. 1-32. [Medline].

  11. Naber KG, Schito G, Botto H, Palou J, Mazzei T. Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): implications for empiric therapy. Eur Urol. 2008 Nov. 54(5):1164-75. [Medline].

  12. Little P, Merriman R, Turner S, Rumsby K, Warner G, Lowes JA, et al. Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study. BMJ. 2010 Feb 5. 340:b5633. [Medline]. [Full Text].

  13. Molander U, Arvidsson L, Milsom I, Sandberg T. A longitudinal cohort study of elderly women with urinary tract infections. Maturitas. 2000 Feb 15. 34(2):127-31. [Medline].

  14. Johnson L, Sabel A, Burman WJ, Everhart RM, Rome M, MacKenzie TD, et al. Emergence of fluoroquinolone resistance in outpatient urinary Escherichia coli isolates. Am J Med. 2008 Oct. 121(10):876-84. [Medline].

  15. [Guideline] American College of Obstetricians and Gynecologists (ACOG). 2008. Treatment of urinary tract infections in nonpregnant women. Available at http://guideline.gov/content.aspx?id=12628. Accessed: September 22, 2010.

  16. Barclay L. Urinary Tract Infection: 3 Questions Aid Diagnosis in Women. Medscape Medical News. Available at http://www.medscape.com/viewarticle/810667. Accessed: September 16, 2013.

  17. Knottnerus BJ, Geerlings SE, Moll van Charante EP, Ter Riet G. Toward a simple diagnostic index for acute uncomplicated urinary tract infections. Ann Fam Med. 2013 Sep-Oct. 11(5):442-51. [Medline]. [Full Text].

  18. Schaeffer AJ, Schaeffer EM. Infections of the Urinary Tract. In: McDougal WS, Wein AJ, Kavoussi LR, et al, eds. Campbell-Walsh Urology. 10th Ed. Philadelphia, PA: Elsevier Saunders; 2012. 46-55.

  19. Lifshitz E, Kramer L. Outpatient urine culture: does collection technique matter?. Arch Intern Med. 2000 Sep 11. 160(16):2537-40. [Medline].

  20. Propp DA, Weber D, Ciesla ML. Reliability of a urine dipstick in emergency department patients. Ann Emerg Med. 1989 May. 18(5):560-3. [Medline].

  21. Mehnert-Kay SA. Diagnosis and Management of Uncomplicated Urinary Tract Infections. American Family Physician. August 1, 2005. 27/No.3:1-9. [Full Text].

  22. [Guideline] Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010 Apr. 31(4):319-26. [Medline]. [Full Text].

  23. Kauffman CA, Fisher JF, Sobel JD, Newman CA. Candida urinary tract infections--diagnosis. Clin Infect Dis. 2011 May. 52 Suppl 6:S452-6. [Medline].

  24. Falagas ME, Kotsantis IK, Vouloumanou EK, Rafailidis PI. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta-analysis of randomized controlled trials. J Infect. 2009 Feb. 58(2):91-102. [Medline].

  25. Foxman B. The epidemiology of urinary tract infection. Nat Rev Urol. 2010 Dec. 7(12):653-60. [Medline].

  26. Little P, Moore MV, Turner S, Rumsby K, Warner G, Lowes JA, et al. Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. BMJ. 2010 Feb 5. 340:c199. [Medline]. [Full Text].

  27. Christiaens TC, De Meyere M, Verschraegen G, Peersman W, Heytens S, De Maeseneer JM. Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. Br J Gen Pract. 2002 Sep. 52(482):729-34. [Medline]. [Full Text].

  28. Bleidorn J, Gágyor I, Kochen MM, Wegscheider K, Hummers-Pradier E. Symptomatic treatment (ibuprofen) or antibiotics (ciprofloxacin) for uncomplicated urinary tract infection?--results of a randomized controlled pilot trial. BMC Med. 2010 May 26. 8:30. [Medline]. [Full Text].

  29. Olson RP, Harrell LJ, Kaye KS. Antibiotic resistance in urinary isolates of Escherichia coli from college women with urinary tract infections. Antimicrob Agents Chemother. 2009 Mar. 53(3):1285-6. [Medline]. [Full Text].

  30. McKinnell JA, Stollenwerk NS, Jung CW, Miller LG. Nitrofurantoin compares favorably to recommended agents as empirical treatment of uncomplicated urinary tract infections in a decision and cost analysis. Mayo Clin Proc. 2011 Jun. 86(6):480-8. [Medline]. [Full Text].

  31. Falagas ME, Vouloumanou EK, Togias AG, Karadima M, Kapaskelis AM, Rafailidis PI, et al. Fosfomycin versus other antibiotics for the treatment of cystitis: a meta-analysis of randomized controlled trials. J Antimicrob Chemother. 2010 Sep. 65(9):1862-77. [Medline]. [Full Text].

  32. [Guideline] Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1. 40(5):643-54. [Medline]. [Full Text].

  33. Dalal S, Nicolle L, Marrs CF, Zhang L, Harding G, Foxman B. Long-term Escherichia coli asymptomatic bacteriuria among women with diabetes mellitus. Clin Infect Dis. 2009 Aug 15. 49(4):491-7. [Medline]. [Full Text].

  34. Beerepoot MA, ter Riet G, Nys S, et al. Cranberries vs antibiotics to prevent urinary tract infections: a randomized double-blind noninferiority trial in premenopausal women. Arch Intern Med. 2011 Jul 25. 171(14):1270-8. [Medline].

  35. Jepson RG, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2008 Jan 23. CD001321. [Medline].

  36. Tempera G, Corsello S, Genovese C, Caruso FE, Nicolosi D. Inhibitory activity of cranberry extract on the bacterial adhesiveness in the urine of women: an ex-vivo study. Int J Immunopathol Pharmacol. 2010 Apr-Jun. 23(2):611-8. [Medline].

  37. De Vita D, Giordano S. Effectiveness of intravesical hyaluronic acid/chondroitin sulfate in recurrent bacterial cystitis: a randomized study. Int Urogynecol J. 2012 Dec. 23(12):1707-13. [Medline].

  38. van der Starre WE, van Nieuwkoop C, Paltansing S, et al. Risk factors for fluoroquinolone-resistant Escherichia coli in adults with community-onset febrile urinary tract infection. J Antimicrob Chemother. 2011 Mar. 66(3):650-6. [Medline].

  39. Cunha BA. Prophylaxis for recurrent urinary tract infections: nitrofurantoin, not trimethoprim-sulfamethoxazole or cranberry juice. Arch Intern Med. 2012 Jan 9. 172(1):82; author reply 82-3. [Medline].

  40. Cunha BA, Schoch PE, Hage JR. Nitrofurantoin: preferred empiric therapy for community-acquired lower urinary tract infections. Mayo Clin Proc. 2011 Dec. 86(12):1243-4; author reply 1244. [Medline]. [Full Text].

  41. Fischer HD, Juurlink DN, Mamdani MM, Kopp A, Laupacis A. Hemorrhage during warfarin therapy associated with cotrimoxazole and other urinary tract anti-infective agents: a population-based study. Arch Intern Med. 2010 Apr 12. 170(7):617-21. [Medline].

  42. Hand L. Urinary Infections: Report Offers Long-Needed Clarity. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/814305. Accessed: November 18, 2013.

  43. Hooton TM, Roberts PL, Cox ME, Stapleton AE. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med. 2013 Nov 14. 369(20):1883-91. [Medline].

  44. Leydon GM, Turner S, Smith H, Little P. Women's views about management and cause of urinary tract infection: qualitative interview study. BMJ. 2010 Feb 5. 340:c279. [Medline]. [Full Text].

  45. Pinson AG, Philbrick JT, Lindbeck GH, Schorling JB. ED management of acute pyelonephritis in women: a cohort study. Am J Emerg Med. 1994 May. 12(3):271-8. [Medline].

  46. Turner D, Little P, Raftery J, Turner S, Smith H, Rumsby K, et al. Cost effectiveness of management strategies for urinary tract infections: results from randomised controlled trial. BMJ. 2010 Feb 5. 340:c346. [Medline]. [Full Text].

 
Previous
Next
 
Nonobstructing distal left ureteral calculus 2 X 1 X 2 cm.
Multiple abscesses, upper pole of left kidney.
Bilateral hydronephrosis.
Plain radiograph in a 63-year-old patient with poorly controlled type 2 diabetes mellitus shows emphysematous cystitis.
Lactobacilli and a squamous epithelial cell are evident on this vaginal smear. The presence of squamous cells and lactobacilli on urinalysis suggests contamination or colonization. Source: Centers for Disease Control and Prevention, Dr. Mike Miller
Table 1. Treatment Regimens for Uncomplicated Cystitis in Nonpregnant Women [1]
First-line therapy
  • trimethoprim/sulfamethoxazole * 160 mg/800 mg (Bactrim DS, Septra DS) 1 tablet PO BID for 3d (use when bacterial resistance is < 20% and patient has no allergy) or
  • nitrofurantoin monohydrate/macrocrystals (Macrobid) 100 mg PO BID for 5-7d or
  • nitrofurantoin macrocrystals (Macrodantin) 50-100 mg PO QID for 7d or
  • fosfomycin (Monurol) 3 g PO as a single dose with 3-4 oz of water
Second-line therapy
  • ciprofloxacin (Cipro) 250 mg PO BID for 3d or
  • ciprofloxacin extended release (Cipro XR) 500 mg PO daily for 3d or
  • levofloxacin (Levaquin) 250 mg PO q24h for 3d or
  • ofloxacin 200 mg PO q12h for 3d
Alternative therapy
  • amoxicillin-clavulanate (Augmentin) 500 mg/125 mg PO BID for 3-7d or
  • amoxicillin-clavulanate (Augmentin) 250 mg/125 mg PO TID for 3-7d or
  • cefdinir 300 mg PO BID for 7d or
  • cefaclor 500 mg PO TID for 7d or
  • cefpodoxime 100 mg PO BID for 7d or
  • cefuroxime 250 mg PO BID for 7-10d
*Should generally be avoided in elderly patients because of the risk of affecting renal function.
Table 2. Treatment Regimens for Complicated Cystitis in Nonpregnant Women [15]
First-line therapy
Oral:



Patients with complicated cystitis who can tolerate oral therapy may be treated with the following options:



  • ciprofloxacin (Cipro) 500 mg PO BID for 7-14d or
  • ciprofloxacin extended release (Cipro XR) 1 g PO daily for 7-14d or
  • levofloxacin (Levaquin) 750 mg PO daily for 5d
Parenteral:



Patients who cannot tolerate oral therapy as outlined above or patients with infection that is suspected to be due to resistant organisms should be treated with parenteral therapy, as follows:



  • ciprofloxacin (Cipro) 400 mg IV q12h for 7-14d or
  • levofloxacin (Levaquin) 750 mg IV daily for 5d or
  • ampicillin 1-2 g IV q6h plus gentamicin 2 mg/kg/dose q8h for 7-14d or
  • piperacillin-tazobactam (Zosyn) 3.375 g IV q6h or
  • doripenem 500 mg (Doribax) IV q8h for 10d or
  • imipenem-cilastatin (Primaxin) 500 mg IV q6h for 7-14d or
  • meropenem (Merrem) 1 g IV q8h for 7-14d
Duration of therapy: shorter courses (7d) are reasonable if patient improves rapidly; longer courses (10-14d) are reasonable if patient has a delayed response or is hospitalized.



Parenteral therapy can be switched to oral therapy once clinical improvement is observed.



Second-line therapy
  • cefepime (Maxipime) 2 g IV q12h for 10d or
  • ceftazidime (Fortaz, Tazicef) 500 mg IV or IM q8-12h for 7-14d
Duration of therapy: shorter courses (7d) are reasonable if patient improves rapidly; longer courses (10-14d) are reasonable if patient has a delayed response or is hospitalized.



Parenteral therapy can be switched to oral therapy once clinical improvement is observed.



Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.