Cysyitis management
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Cystitis: Management
Definition & Classification
- Uncomplicated cystitis: Lower UTI (bladder) in an otherwise healthy, non-pregnant woman
- Complicated cystitis: UTI in patients with anatomic abnormalities, obstruction, immunosuppression, pregnancy, indwelling catheter, or unusual pathogens
- Recurrent cystitis: Recurrence due to reinfection or relapse (common in women)
— Washington Manual of Medical Therapeutics; Harrison's Principles of Internal Medicine 22E
Microbiology
The predominant pathogen is E. coli (~80–85%). Others include Klebsiella, Staphylococcus saprophyticus (especially in young women), Proteus, and Enterococcus. MDR organisms are increasingly prevalent.
Clinical Features
| Feature | Cystitis | Suggests Upper Tract / Complicated |
|---|---|---|
| Dysuria, frequency, urgency | ✓ | — |
| Suprapubic discomfort | ✓ | — |
| Gross hematuria | ✓ | — |
| Fever, rigors, flank pain | ✗ | Pyelonephritis / sepsis |
| Nausea/vomiting | ✗ | Pyelonephritis |
Fever is inconsistent with uncomplicated cystitis — if present, consider pyelonephritis or prostatitis. — Harrison's 22E
Diagnosis
Women
- Uncomplicated presentation: Can be treated empirically on history alone
- Urine dipstick (nitrite/leukocyte esterase): useful but a negative dipstick does not rule out UTI
- Urine culture indicated in:
- Pregnant patients
- Suspected resistant organism
- Recurrent UTI
- Atypical symptoms
- Sterile pyuria: consider Chlamydia trachomatis, Ureaplasma, N. gonorrhoeae, M. tuberculosis, or interstitial cystitis
Men
- Cystitis is uncommon except with catheterization or obstructive uropathy (BPH)
- Always obtain urine culture — differentiates bacterial prostatitis (bacteriuria present) from chronic pelvic pain syndrome (no bacteriuria)
- Exclude ABP, CBP, and pyelonephritis before diagnosing uncomplicated cystitis
Treatment
Acute Uncomplicated Cystitis in Women
| Drug | Dose | Duration | Notes |
|---|---|---|---|
| Nitrofurantoin (macrocrystals) | 100 mg BD | 5–7 days | First line; nausea/headache common |
| TMP-SMX | 1 DS tablet BD | 3 days | First line; check local resistance |
| Fosfomycin | 3 g sachet | Single dose | Good for MDR E. coli; ESBL strains |
| Pivmecillinam | 400 mg BD | 3–7 days | Approved in USA 2024; MDR activity |
| Fluoroquinolones | Varies | 3 days | Reserve — collateral damage risk |
| β-Lactams (e.g., cephalexin) | Varies | 5–7 days | Higher failure rates vs FQ/TMP-SMX |
Key prescribing points:
- Choose antibiotics based on local susceptibility/resistance patterns (antibiogram)
- Extend to 7 days for diabetics and older patients
- β-Lactams: avoid if early pyelonephritis is suspected (poor tissue concentration)
- Fluoroquinolones are NOT first-line due to resistance selection and side-effect profile; β-lactams are preferred over FQs as an alternative
- Fosfomycin is particularly useful when MDR E. coli (including some ESBL-producers) is a concern
— Harrison's 22E, Table 40-1; Washington Manual, Table 14-11
Cystitis in Pregnancy
| Drug | Duration |
|---|---|
| Nitrofurantoin | 7 days (avoid at term — risk of hemolytic anemia in neonate) |
| Cephalexin | 7 days |
| Cefuroxime axetil | 7 days |
- Treat asymptomatic bacteriuria in pregnancy (risk of pyelonephritis and preterm birth)
- Avoid TMP-SMX in first trimester (folate antagonism) and near term
Cystitis in Men
| Drug | Duration |
|---|---|
| TMP-SMX | 7–14 days |
| Fluoroquinolone | 7–14 days |
- Avoid nitrofurantoin and β-lactams in men — inadequate tissue concentrations for potential prostate involvement
- Shorter durations (< 7 days) are not adequately studied in men
Complicated & Catheter-Associated Cystitis
- Culture before treatment
- Treat for 7–14 days based on susceptibility
- Remove or change urinary catheter if possible
- Carbapenem or β-lactam/β-lactamase inhibitor combinations for ESBL/MDR organisms (guided by culture)
Recurrent Cystitis in Women
Definition
- ≥2 infections in 6 months or ≥3 in 12 months
Prevention Strategies
| Strategy | Details |
|---|---|
| Behavioral modifications | Post-coital voiding, adequate hydration, avoid spermicides |
| Post-coital prophylaxis | Single-dose TMP-SMX or nitrofurantoin after intercourse |
| Continuous low-dose prophylaxis | Nightly TMP-SMX, nitrofurantoin, or cephalexin for 6–12 months |
| Self-start therapy | Patient-initiated 3-day course at onset of symptoms |
| Topical estrogen | Post-menopausal women: vaginal estrogen cream reduces recurrences |
| Cranberry products | Modest evidence; can be offered as adjunct |
| D-mannose | Some evidence for prevention; generally well tolerated |
Special Populations
Asymptomatic Bacteriuria (ASB)
- Treat: Pregnancy, prior to urologic procedures
- Do NOT treat routinely: Elderly, diabetics, catheterized patients, or spinal cord injury (no outcome benefit, increases resistance)
Interstitial Cystitis (IC/BPS)
- Chronic pelvic pain + urinary symptoms without infection
- Sterile urine culture
- Management: behavioral therapy, pentosan polysulfate (Elmiron), intravesical treatments, amitriptyline, hydrodistension
When to Escalate / Refer
| Scenario | Action |
|---|---|
| Fever, flank pain, rigors | Treat as pyelonephritis |
| Failure to respond to therapy | Urine culture + sensitivities |
| Male with recurrent UTI | Evaluate for prostatitis, urologic abnormality |
| Obstructive uropathy suspected | CT/ultrasound imaging |
| MDR organism on culture | Infectious disease/urology referral |
Sources:
- Harrison's Principles of Internal Medicine 22E (2025), Ch. 140
- Washington Manual of Medical Therapeutics, Ch. 14
- Goldman-Cecil Medicine, Ch. 268
- Textbook of Family Medicine 9e, Ch. 14
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