Cystitis medical therapy: Difference between revisions

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==Overview==
==Overview==
Because of the risk of the infection spreading to the kidneys (complicated [[Urinary tract infection|UTI]]) and due to the high complication rate in the elderly population and in diabetics, prompt treatment is almost always recommended.
Antimicrobial therapy is indicated in cystitis.  The treatment of cystitis depends on the disease course (acute uncomplicated vs. complicated) and the rates of resistance in the community.  Due to the risk of the infection spreading to the kidneys (complicated [[Urinary tract infection|UTI]]) and the high complication rate in diabetics and the elderly population, prompt treatment is almost always recommended.
 
==Principles of Medical Therapy==
==Principles of Medical Therapy==
*Acute uncomplicated cystitis definition includes  Premenopausal, nonpregnant women with no known urological abnormalities or comorbidities,[[postmenopause|postmenopausal]] women or well-controlled diabetic female patients.<ref name="pmid21292654">{{cite journal| author=Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al.| title=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. | journal=Clin Infect Dis | year= 2011 | volume= 52 | issue= 5 | pages= e103-20 | pmid=21292654 | doi=10.1093/cid/ciq257 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21292654  }} </ref>
*Acute uncomplicated cystitis definition includes  Premenopausal, nonpregnant women with no known urological abnormalities or comorbidities,[[postmenopause|postmenopausal]] women or well-controlled diabetic female patients.<ref name="pmid21292654">{{cite journal| author=Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al.| title=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. | journal=Clin Infect Dis | year= 2011 | volume= 52 | issue= 5 | pages= e103-20 | pmid=21292654 | doi=10.1093/cid/ciq257 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21292654  }} </ref>

Revision as of 12:57, 17 August 2015

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Steven C. Campbell, M.D., Ph.D.

Overview

Antimicrobial therapy is indicated in cystitis. The treatment of cystitis depends on the disease course (acute uncomplicated vs. complicated) and the rates of resistance in the community. Due to the risk of the infection spreading to the kidneys (complicated UTI) and the high complication rate in diabetics and the elderly population, prompt treatment is almost always recommended.

Principles of Medical Therapy

  • Acute uncomplicated cystitis definition includes Premenopausal, nonpregnant women with no known urological abnormalities or comorbidities,postmenopausal women or well-controlled diabetic female patients.[1]
  • The decision to use antimicrobials should be case baesd, in other words it should depend on the patients specifics like allergy and compliance history, availability and cost of treatment and resistant rates at the local community.
  • TMP-SMX is preferred to use in areas where the resistance rates are less than 20%.[8][9]
  • Nitrofurantoin, fosfomycin and mecillinam shouldn't be used when pyelonephritis is suspected, because they have weak penetration to the renal tissue.
  • Use of broad-spectrum antimicrobials like fluoroquinolones resulted multidrug resistant organisms,[10]so they are used as alternative to the first line drugs in case of allergy, unavailability or intolerance.[11][12]
  • Beta-lactams have less efficacy than fluoroquinolones. While ampicillin and amoxicillin should be avoided due to high rate of resistance.[13][14]
  • Post-therapy urine culture is recommended only for pregnant women,[15] multiple early recurrences with the same strain of bacteria and for persistent hematuria.

Acute Uncomplicated Cystitis

Complicated/Catheter Associated cystitis

All men considered as complicated infection, others include pregnant women and children with metabolic or anatomical abnoramlities, as a general rule all patients with risk of serious complications and/or failure of treatment(stones, obstruction, immunocompromised patients, neurogenic bladder, renal failure,transplant patients) considered as complicated infections[16]

  • Urinary infections in catheterized patients tend to be polymicrobial with more resistant uropathogens.
  • Urine culture:should be taken before initiation the antimicrobial therapy.[17] For infected patients with indwelling catheters more than 2 weeks, the catheter should be replaced, and urine culture should be sampled from the new catheter to improve the out come of treatment with less complications.[18]

Duration of Treatment

  • Depends on the response to treatment regardless if the catheter is still placed or not. For quick resolution, a 7 days regimen is recommended. While delayed clinical improvement needs extended regimen (10-14 days).[19]
  • For mild catheter associated UTI, levofloxacin for 5 days is recommended. While 3 days regimen of antimicrobials is recommended for women ≤65 with lower urinary symptoms only after catheter removal.[20]

Cystitis in Pregnancy

Recurrent Cystitis

Recurrent cystitis suggests antimicrobial resistance.

  • Recurrence or persistence of urinary symptoms within one or two weeks of treatment of uncomplicated cystitis, the treatment should be initiated after urine culture with broad-spectrum fluoroquinolones.
  • Recurrence at least one month after successful treatment is treated with first line, short course(7 days) regimen.
  • Recurrence within 6 month of successful treatment should be treated with another first line agent than the one used first time.[23]
  • In postmenopausal women, it's recommended to evaluate correctable factors like cystocele, incontinence and residual urine volume ≥50 ml.

==Empiric Therapy for Acute Cystitis== Adapted from Clin Infect Dis. 2011;52(5):e103-20.[24]


Acute Bacterial Uncomplicated Cystitis
Preferred Regimen
Nitrofurantoin 100 mg PO q12h × 5 days
OR
TMP 100 mg PO q12h ×3 days
OR
Fosfomycin 3 gm PO single dose
OR If resistence<20% or if used for UTI >3 months
TMP-SMX ‡ 1 DS tab PO q12h × 3 days
OR Not FDA approved but used in some European countries
Pivmecillinam 400 mg PO q12h 3-7 days
Alternative Regimen
Fluoroquinolones for 3 days
Ofloxacin 200–400 mg PO bid
OR
Ciprofloxacin 250 mg bid PO or Cipro XR 500 mg q24h
OR
Levofloxacin 250–750 mg PO q24
OR β-lactam agents for 3-7 days
Amoxicillin-clavulanate 500/125 mg PO q8h or 875/125 mg PO q8h
OR
Cefdinir 300 mg PO q12h or 600 mg PO q24
OR
Cefaclor 250-500 mg PO q8h
OR
Cefpodoxime proxetil 100-200 mg PO q12h
OR
Cephalexin250-500 mg PO q6h not studied well but effective.
Complicated/Catheter Associated Cystitis
Preferred Regimen
Mild Infection
Levofloxacin 750 mg PO q24 × 5 days
Delayed Response
Levofloxacin 750 mg PO q24 × 10-14 days
After Catheter Removal
Levofloxacin 750 mg PO q24 × 3 days
Acute Cystitis in Pregnancy
Preferred Regimen
Nitrofurantoin 100 mg PO q12h × 3-5 days
OR
Fosfomycin 3 g PO single dose
OR
Amoxicillin-clavulanate 500/125 mg PO q12h × 3-5 days
OR
Amoxicillin 500 mg PO q12h × 3-5 days
OR
Cephalexin 500 mg PO q12h × 3-5 days
OR
TMP-SMX DS 1 tab PO q12h × 3-5 days
avoid in first trimester(TMP) and third trimester (SMX).

References

  1. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG; et al. (2011). "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. 52 (5): e103–20. doi:10.1093/cid/ciq257. PMID 21292654.
  2. Kahlmeter, G. (2003). "An international survey of the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections: the ECO.SENS Project". J Antimicrob Chemother. 51 (1): 69–76. PMID 12493789. Unknown parameter |month= ignored (help)
  3. Naber, KG.; Schito, G.; Botto, H.; Palou, J.; Mazzei, T. (2008). "Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): implications for empiric therapy". Eur Urol. 54 (5): 1164–75. doi:10.1016/j.eururo.2008.05.010. PMID 18511178. Unknown parameter |month= ignored (help)
  4. Gupta, K.; Hooton, TM.; Roberts, PL.; Stamm, WE. (2007). "Short-course nitrofurantoin for the treatment of acute uncomplicated cystitis in women". Arch Intern Med. 167 (20): 2207–12. doi:10.1001/archinte.167.20.2207. PMID 17998493. Unknown parameter |month= ignored (help)
  5. Iravani, A.; Klimberg, I.; Briefer, C.; Munera, C.; Kowalsky, SF.; Echols, RM. (1999). "A trial comparing low-dose, short-course ciprofloxacin and standard 7 day therapy with co-trimoxazole or nitrofurantoin in the treatment of uncomplicated urinary tract infection". J Antimicrob Chemother. 43 Suppl A: 67–75. PMID 10225575. Unknown parameter |month= ignored (help)
  6. Stein, GE. (1999). "Comparison of single-dose fosfomycin and a 7-day course of nitrofurantoin in female patients with uncomplicated urinary tract infection". Clin Ther. 21 (11): 1864–72. doi:10.1016/S0149-2918(00)86734-X. PMID 10890258. Unknown parameter |month= ignored (help)
  7. Minassian, MA.; Lewis, DA.; Chattopadhyay, D.; Bovill, B.; Duckworth, GJ.; Williams, JD. (1998). "A comparison between single-dose fosfomycin trometamol (Monuril) and a 5-day course of trimethoprim in the treatment of uncomplicated lower urinary tract infection in women". Int J Antimicrob Agents. 10 (1): 39–47. PMID 9624542. Unknown parameter |month= ignored (help)
  8. Gupta, K. (2003). "Emerging antibiotic resistance in urinary tract pathogens". Infect Dis Clin North Am. 17 (2): 243–59. PMID 12848469. Unknown parameter |month= ignored (help)
  9. Raz, R.; Chazan, B.; Kennes, Y.; Colodner, R.; Rottensterich, E.; Dan, M.; Lavi, I.; Stamm, W. (2002). "Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with a high prevalence of TMP-SMX-resistant uropathogens". Clin Infect Dis. 34 (9): 1165–9. doi:10.1086/339812. PMID 11941541. Unknown parameter |month= ignored (help)
  10. Hooton, TM.; Besser, R.; Foxman, B.; Fritsche, TR.; Nicolle, LE. (2004). "Acute uncomplicated cystitis in an era of increasing antibiotic resistance: a proposed approach to empirical therapy". Clin Infect Dis. 39 (1): 75–80. doi:10.1086/422145. PMID 15206056. Unknown parameter |month= ignored (help)
  11. Paterson, DL. (2004). "Collateral damage from cephalosporin or quinolone antibiotic therapy". Clin Infect Dis. 38 Suppl 4: S341–5. doi:10.1086/382690. PMID 15127367. Unknown parameter |month= ignored (help)
  12. Ramphal, R.; Ambrose, PG. (2006). "Extended-spectrum beta-lactamases and clinical outcomes: current data". Clin Infect Dis. 42 Suppl 4: S164–72. doi:10.1086/500663. PMID 16544267. Unknown parameter |month= ignored (help)
  13. Rodríguez-Baño, J.; Alcalá, JC.; Cisneros, JM.; Grill, F.; Oliver, A.; Horcajada, JP.; Tórtola, T.; Mirelis, B.; Navarro, G. (2008). "Community infections caused by extended-spectrum beta-lactamase-producing Escherichia coli". Arch Intern Med. 168 (17): 1897–902. doi:10.1001/archinte.168.17.1897. PMID 18809817. Unknown parameter |month= ignored (help)
  14. Hooton, TM.; Scholes, D.; Gupta, K.; Stapleton, AE.; Roberts, PL.; Stamm, WE. (2005). "Amoxicillin-clavulanate vs ciprofloxacin for the treatment of uncomplicated cystitis in women: a randomized trial". JAMA. 293 (8): 949–55. doi:10.1001/jama.293.8.949. PMID 15728165. Unknown parameter |month= ignored (help)
  15. Nicolle, LE.; Bradley, S.; Colgan, R.; Rice, JC.; Schaeffer, A.; Hooton, TM. (2005). "Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults". Clin Infect Dis. 40 (5): 643–54. doi:10.1086/427507. PMID 15714408. Unknown parameter |month= ignored (help)
  16. Hooton, TM. (2012). "Clinical practice. Uncomplicated urinary tract infection". N Engl J Med. 366 (11): 1028–37. doi:10.1056/NEJMcp1104429. PMID 22417256. Unknown parameter |month= ignored (help)
  17. Nicolle, LE. (2001). "A practical guide to antimicrobial management of complicated urinary tract infection". Drugs Aging. 18 (4): 243–54. PMID 11341472.
  18. Raz, R.; Schiller, D.; Nicolle, LE. (2000). "Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection". J Urol. 164 (4): 1254–8. PMID 10992375. Unknown parameter |month= ignored (help)
  19. "The prevention and management of urinary tract infections among people with spinal cord injuries. National Institute on Disability and Rehabilitation Research Consensus Statement. January 27-29, 1992". J Am Paraplegia Soc. 15 (3): 194–204. 1992. PMID 1500945. Unknown parameter |month= ignored (help)
  20. Mohler, JL.; Cowen, DL.; Flanigan, RC. (1987). "Suppression and treatment of urinary tract infection in patients with an intermittently catheterized neurogenic bladder". J Urol. 138 (2): 336–40. PMID 3496470. Unknown parameter |month= ignored (help)
  21. Ben David, S.; Einarson, T.; Ben David, Y.; Nulman, I.; Pastuszak, A.; Koren, G. (1995). "The safety of nitrofurantoin during the first trimester of pregnancy: meta-analysis". Fundam Clin Pharmacol. 9 (5): 503–7. PMID 8617414.
  22. Crider, KS.; Cleves, MA.; Reefhuis, J.; Berry, RJ.; Hobbs, CA.; Hu, DJ. (2009). "Antibacterial medication use during pregnancy and risk of birth defects: National Birth Defects Prevention Study". Arch Pediatr Adolesc Med. 163 (11): 978–85. doi:10.1001/archpediatrics.2009.188. PMID 19884587. Unknown parameter |month= ignored (help)
  23. Hooton, TM. (2012). "Clinical practice. Uncomplicated urinary tract infection". N Engl J Med. 366 (11): 1028–37. doi:10.1056/NEJMcp1104429. PMID 22417256. Unknown parameter |month= ignored (help)
  24. Gupta, K.; Hooton, TM.; Naber, KG.; Wullt, B.; Colgan, R.; Miller, LG.; Moran, GJ.; Nicolle, LE.; Raz, R. (2011). "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. 52 (5): e103–20. doi:10.1093/cid/ciq257. PMID 21292654. Unknown parameter |month= ignored (help)

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