Acute cystitis

Most common form is acute uncomplicated cystitis with acute onset of dysuria, frequency, or urgency in a healthy, nonpregnant woman without functional or anatomical abnormalities of the urinary tract.

Accounts for more than 8 million office visits annually.

Acute cystitis manifests usually with dysuria, urinary frequency, urgency, suprapubic pain, hematuria, or a combination of the symptoms.

Risk factors in young women are history of previous episodes of cystitis and frequent or recent sexual activity.

Celibate women rarely have cystitis.

Cystitis:pyelonephritis, 1:28.

Following sexual activity the risk of acute cystitis at 48 hours increases by 60 times.

Women with diabetes have 2 times the risk than nondiabetic women.

Among elderly women the risk increases with age, debility, neurologic disease and dementia.

Accounts for 3.6 million physician office visits by women 18-75 years of age per year.

Bacteria colonize the vagina, perineum and periurethral tissues and ascend to the bladder, commonly after sexual intercourse.

Bladder invasion by bacteria may lead to a symptomatic urinary tract infection depending upon genetic, biological, and behavioral factors.

Symptomatic cystitis is associated with abrupt onset of dysuria, urinary frequency, and urinary urgency.

The likelihood that a patient may experiencing UTI is increased by the presence of hematuria, suprapubic pain, turbid urine, malodorous urine, incontinence, recent intercourse, and recent antibiotic administration.

A combination of dysuria, and urinary frequency without vaginal discharge as a 96% positive prediction value in diagnosing a UTI, and a urinalysis or urine culture can be eliminated.

Current management in women with uncomplicated infections is empirical use of antibiotics without the use of urine cultures or susceptibility testing.

Acute uncomplicated cystitis is a benign condition that rarely progresses to severe disease, even if left untreated.

Primary treatment is the amelioration of symptoms.

The current drug of choice in the U.S. for empirical therapy for uncomplicated UTI in women is trimethoprim-sulfamethoxazole.

Urine cultures and sensitivity studies are reserved for patients who are pregnant, or who had symptoms of upper tract disease, have a high risk factor for resistant organisms, or experience therapeutic failure or early relapse.

Cystitis is a mucosal infection and most antibiotics achieve high urinary concentrations and therefore treatment for only a few days results in resolution of symptoms and bactiuria in 90-95% of patients (Nicolle LE).

Three days of treatment with B. I D. trimethoprim-sulfamethoxazole (TMP-SMZ) or trimethoprim alone has been accepted first-line treatment for acute uncomplicated cystitis.

TMP-SMZ can achieve very high urine concentrations and can eliminate bacteria from the vaginal-perineal reservoir.

Use of TMP-SMZ has been associated with increased drug resistance.

Because of increasing resistance patterns to TMP-SMZ, a three-day course of a fluoroquinolone as first-line therapy for uncomplicated cystitis has been advocated by many clinicians.

Recently however fluoroquinolones are no longer recommended as initial treatment because they have a propensity for collateral damage.

The antimicrobial agent chosen is individualized based on: the patients allergy and adherence history, local practice patterns, prevalence of resistance in the community, medication availability, patients and provider’s threshold for failure.

Antibiotic choice is often influenced by cost, as well as patient comorbidities such as renal disease.

A prior urine culture is useful in predicting the identity and susceptibility of a pathogen drink after a rpositive urine culture results, even weeks to months later.

In a review of 27 randomized clinical trial’s, six systemic reviews, and 11 observational studies: acute uncomplicated cystitis in women can be diagnosed without an office visit or urine culture (Grigoryan L et al).

In the above studies immediate anti-microbial therapy with trimethoprim-sulfamethoxazole, nitrofurantoin or fosfomycin is indicated for acute cystitis in adult women.

Recently increased resistance to fluoroquinolones by E. coli isolates have complicated management of cystitis with such drugs.

Fluoroquinolones may be associated with severe Clostridium difficile colitis.

A clinical trial of nitrofurantoin macrocrystals BID was equivalent or superior to a 3 day standard TMP-SMZ in uncomplicated UTI (Gupta K et al).

Antimicrobial resistance is increased over the past decade.

Most studies demonstrate beta-lactam antibiotics are generally inferior to trimethoprim-sulfamethoxazole and fluoroquinolones in the treatment cystitis.

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