Cystitis medical therapy: Difference between revisions
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! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Acute Bacterial Uncomplicated Cystitis}} | ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Acute Bacterial Uncomplicated Cystitis}} | ||
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| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen''''' | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen''''' | ||
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| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nitrofurantoin]] 100 mg PO q12h×5 days'''''<br>OR<br>▸ '''''[[TMP-SMX]] ‡ 1 DS tab PO q12h×3 days'''''<br>OR<br>▸ '''''[[TMP]] 100 mg PO bid ×3 days<br>OR<br>▸ '''''[[Fosfomycin]] 3 gm PO single dose'''''<br>OR<br>▸ '''''[[Pivmecillinam]] 400 mg PO bid×5 days''''' | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nitrofurantoin]] 100 mg PO q12h×5 days'''''<br>OR<br>▸ '''''[[TMP-SMX]] ‡ 1 DS tab PO q12h×3 days'''''<br>OR<br>▸ '''''[[TMP]] 100 mg PO bid ×3 days'''''<br>OR<br>▸ '''''[[Fosfomycin]] 3 gm PO single dose'''''<br>OR<br>▸ '''''[[Pivmecillinam]] 400 mg PO bid×5 days''''' | ||
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| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen''''' | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen''''' | ||
Revision as of 23:02, 24 February 2014
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Steven C. Campbell, M.D., Ph.D.
Overview
Because of the risk of the infection spreading to the kidneys (complicated UTI) and due to the high complication rate in the elderly population and in diabetics, 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.
- Being the most common cause of cystitis (75-90%), E.Coli susceptibility should be considered to choose the appropriate empirical antimicrobial. Other organisms like Proteus mirabilis, Klebsiella pneumoniae and Staphylococcus saprophyticus are less common.
- Nitrofurantoin, fosfomycin and mecillinam are prefered as first line treatment because have less resistance among other antibacterials [2][3]with similar efficacy.[4][5][6][7]
- 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.
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]
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.[21]
- In postmenopausal women, it's recommended to evaluate correctable factors like cystocele, incontinence and residual urine volume ≥50 ml.
Empiric Therapy
Acute uncomplicated cystitis definition includes Premenopausal, nonpregnant women with no known urological abnormalities or comorbidities,postmenopausal women or well-controlled diabetes female patients.[1]
| Acute Bacterial Uncomplicated Cystitis |
|---|
| Preferred Regimen |
| ▸ Nitrofurantoin 100 mg PO q12h×5 days OR ▸ TMP-SMX ‡ 1 DS tab PO q12h×3 days OR ▸ TMP 100 mg PO bid ×3 days OR ▸ Fosfomycin 3 gm PO single dose OR ▸ Pivmecillinam 400 mg PO bid×5 days |
| Alternative Regimen |
| ▸ Fluoroquinolones for 3 days Ofloxacin 200–400 mg PO bid. Ciprofloxacin 250 mg bid PO or Cipro XR 500 mg q24h Levofloxacin 250–750 mg PO q24 OR ▸ β-lactam agents for 3-7 days Amoxicillin-clavulanate 500/125 mg po tid or 875/125 mg po bid Cefdinir 300 mg po q12h or 600 mg po q24 Cefaclor 250-500 mg PO q8h Cefpodoxime proxetil 100-200 mg PO q12h Others(Cephalexin250-500 mg PO q6h ) not studied well but effective. |
|} ‡Avoid if the prevalence of resistance is known to exceed 20% or if used for UTI in previous 3 months. ♦Pivmecillinam is available in some European countries, not licensed in US.
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References
- ↑ 1.0 1.1 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.
- ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ Nicolle, LE. (2001). "A practical guide to antimicrobial management of complicated urinary tract infection". Drugs Aging. 18 (4): 243–54. PMID 11341472.
- ↑ 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) - ↑ "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) - ↑ 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) - ↑ 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)