INDEX

    Uncomplicated UTI/Cystitis – Management

    Cardinal Presentations / Presenting Problems, Infections, Urological

    Last Updated Jun 18, 2020
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    Context

    Uncomplicated UTI or Cystitis

    • Typical symptoms: Dysuria, urinary frequency, urgency, suprapubic pain.
    • No systemic symptoms (fevers, chills, nausea/vomiting), flank pain or CVA tenderness (see Complicated UTI – Management)
    • Clinical diagnosis with typical symptoms: can use urinalysis to help with diagnosis when atypical symptoms.
      • Urine Dipstick and Microscopy (see UTI (Adult) – Diagnosis)
      • Urine culture and sensitivity if risk factors for multi-drug resistant (MDR) gram negative organisms (see below).
    •  Microbiology:
      • E. coli most common. Also Klebsiella, Proteus, S. saprophyticus.
      • Consider MDR gram negative organism risk factors:

    Adapted from UpToDate: Acute simple cystitis in women.

      • Community-acquired ESBL E. coli risk factors include:
        • Age > 60
        • Diabetes mellitus
        • Recurrent UTI
        • Recent fluoroquinolones, cephalosporins (second or third generation), aminopenicillins

    Recommended Treatment

    Approach to Empiric Antibiotic Selection

    Determine risk of infection with MDR gram-negative organism.

    Low Risk of Resistance

    • First-Line
      • Nitrofurantoin (preferred)
        • 100 mg PO BID x 5 days
        • Avoid if suspecting early pyelonephritis or creatinine clearance < 30
      • Trimethoprim-sulfamethoxazole (preferred)
        • One double strength tab (160/800 mg) PO BID x 3 days
        • If regional resistance rate > 20 % do not use
        • Trimethoprim 100 mg BID x 3 days alternative equivalent
      • Fosfomycin
        • 3 grams of powder mixed in water, x 1 PO dose
        • Susceptibility testing not routinely available.
        • Avoid if suspecting early pyelonephritis.
      • The above agents are equally effective.  Considerations include:
        • Allergies
        • Expected adherence
        • Local resistance patterns
        • Recent use of one of the antibiotics in past 3 months. A different first-line antibiotic should be used if this criteria is met.
    • Second-Line
      • Beta-lactams
        • Amoxicillin-clavulanate 500 mg BID x 5-7 d
        • Cefadroxil 500 mg BID x 5-7 d (not first line)
        • Do NOT use Ampicillin or Amoxicillin – high resistance rates.
      • Fluoroquinolones
        • Ciprofloxacin 250 mg q 12h x 3 d
        • Ciprofloxacin 500 mg extended release q 24h x 3 d
        • Levofloxacin 250 mg q 24h x 3 d
        • Try to reserve for more severe infections
        • Increasing resistance rates

    High Risk of Resistance

    • First obtain urine culture and sensitivity.
    • Empiric PO options:
      • Nitrofurantoin (preferred)
        • 100 mg BID x 5d
      • Fosfomycin
        • 3 grams of powder mixed in water, x 1 dose
    • Note: Community Acquired ESBL
      • Limited selection of PO antibiotics:
        • Options include fosfomycin or nitrofurantoin. Amoxacillin-clavulanate may be an option, but use caution as there are reports of resistance.
        • Resistance to ciprofloxacin, trimethoprim-sulfamethoxazole, and cephalosporins.

    Considerations

    • If unable to use empiric oral antibiotic options, can consider in healthy women with uncomplicated UTI to defer treatment until urine culture susceptibility results.
    • If there is possible antibiotic resistance, but concerns for delaying treatment, it is reasonable to treat empirically with that antibiotic, while waiting for urine culture and susceptibility results.
    • If concerned for treatment failure with PO antibiotics, treat with IV antibiotics (see Complicated UTI – Management)
    • Symptomatic Treatment:
      • Antibiotic therapy usually treats symptoms within 48 hours. Dysuria relieved as early as two hours.
      • If severe dysuria, consider phenazopyridine, in addition to prescribed antibiotics.
      • Urinary analgesic:
        • Can use phenazopyridine 200 mg TID PRN x 2d
        • Do not use chronically, as can mask UTI symptoms.
        • Can cause methemoglobinemia.

     Additional Considerations

    • Use regional/institutional antibiogram (in BC, use Spectrum App) to help with empiric antibiotic selection.
    • However, use urine culture and sensitivity to guide treatment, if taken based on above indications (generally not required in Uncomplicated UTI/Cystitis).

    Disposition / Follow-Up

    Uncomplicated UTI/Cystitis are rarely admitted

    Indications to consider admission include

    Follow-up

    • Patients prescribed antibiotics should have healthcare follow-up for resolution of symptoms.
      • Note: if hematuria on initial presentation, repeat urinalysis in approximately 6 weeks following completion of antibiotics to evaluate for persistent hematuria.
    • Urine culture and susceptibility should be followed up to ensure appropriate antibiotics.
    • Patients that do not improve after 1-2 days of antibiotics should return to ED for further workup:
      • UTI mimic?
      • Complicated UTI?
      • Perform urine culture and sensitivity, if not done already.

    Quality Of Evidence?

    Justification

    The above summary is taken from recent literature reviews on emergency department diagnosis and management of UTIs.

    High

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