ID
Recurrent Cystitis
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Recurrent Cystitis
, Recurrent UTI, Recurrent Urinary Tract Infection
Definitions
Recurrent Urinary Tract Infection in young women
One year with 3 or more symptomatic, culture positive
Urinary Tract Infection
s
Recurrent Urinary Tract Infection in postmenopausal women
One year with 3 or more symptomatic, culture positive
Urinary Tract Infection
s OR
Six months with 2 or more
Urinary Tract Infection
s
UTI Relapse
UTI with same organism and serotype presents within 2 weeks of last UTI treatment
Epidemiology
Incidence
of bacteriuria
School age child: 1.2%
Late Teenage years: 2-5%
Additional 1% per decade of life
Incidence
of UTIs for those prone: 2-3 per year
Reduced to <1 per year on prophylaxis
Pathophysiology
Causative organisms
Escherichia coli
(75% of Recurrent UTI)
Enterococcus
faecalis
Proteus
mirabilis
Klebsiella
Staphylococcus
saprophyticus
Inherited factors (esp. in first degree relative with >5 UTIs)
Immune susceptibility (e.g. variation in
Neutrophil
receptors)
May reduce
Bacteria
l clearance or not preventing uroepithelial adherence
Urogenital anatomy variation
Shorter anal-
Urethra
l distance
Types
Infection Classification
Gene
ral
Reinfection represents 99% of Recurrent UTI in women
Vaginal colonization is the most common cause
First Infection
Unresolved Bacteriuria (Refractory Infection)
Bacteria
l resistance to drug selected for treatment
Resistance developed by sensitive
Bacteria
Bacteriuria with 2 different species
Rapid reinfection with a second resistant organism
Azotemia
Analgesic
abuse causing papillary necrosis
Giant staghorn calculi
Noncompliance
Bacteria
l persistance (Same organism recurs)
Infected
Renal Calculi
Chronic Bacterial Prostatitis
Unilateral infected atrophic
Pyelonephritis
Infected pericalyceal
Diverticula
e
Infected nonrefluxing ureteral stumps
Follows Nephrectomy
Medulla
ry sponge
Kidney
s
Polycystic Kidney Disease
Infected
Urachal Cyst
s
Analgesic
abuse causing infected papillary necrosis
Reinfection (Urine cleared, but new infection occurs)
Colonization of vaginal introitus
Vesicoenteric fistulae
Vesicovaginal fistulae
Vesicoureteral Reflux
Voiding dysfunction
Cystocele
Multiple Sclerosis
Neurogenic
Bladder
Immunosuppression
Chronic Renal Insufficiency
Diabetes Mellitus
Immunosuppressant
medications
Instrumentation
Ureteral Stent
Nephrostomy Tube
Intermittent catheterization or indwelling
Urinary Catheter
Risk Factors
Young women with Recurrent UTI (prior to
Menopause
)
Intercourse in the past month >9 times:
Odds Ratio
10.3
Intercourse in the past month 4-8 times:
Odds Ratio
5.8
Age at first UTI >15 years:
Odds Ratio
3.9
Mother with Recurrent UTI:
Odds Ratio
2.3
New sex partner in the last year:
Odds Ratio
1.9
Spermicide
use in the last year:
Odds Ratio
1.8
Scholes (2000) J Infect Dis 182(4): 1177-82 [PubMed]
Postmenopausal women
Estrogen
deficiency alters
Vaginal pH
and decreases Lactobacillus colonization
Incontinence
Urinary Retention
(residual
Urine Volume
>150 ml)
Structural abnormalities (e.g.
Cystocele
)
Type II Diabetes Mellitus
History of
Urinary Tract Infection
(>5)
Activities that increase intraabdominal pressure (e.g. long distance travel or walking)
Differential Diagnosis
See
Dysuria
Consider
Vaginitis
or
Sexually Transmitted Infection
Consider other noninfectious causes (e.g.
Interstitial Cystitis
,
Bladder Cancer
)
Labs
Urinalysis
Consider
Urine Pregnancy Test
Urine Culture
indications
Obtain in at least one of Recurrent Urinary Tract Infections
Breakthrough
Urinary Tract Infection
while on UTI prophylaxis
UTI symptoms >48 hours despite antibiotic treatment
Symptomatic bacteriuria at 2 weeks after 2 weeks of culture-directed antibiotics
Evaluate for
Antibiotic Resistance
or persistent infection nidus
Diagnostics
Post-void
Residual Volume
and urodynamic testing indications
Urinary Incontinence
or
Overactive Bladder
Incomplete
Bladder
emptying
Structural evaluation (pelvic exam,
Ultrasound
, CT, cystoscopy) indications
Hematuria
persists after infection clearance
Urinary tract malignancy history
Urogenital surgery or
Trauma History
Diverticulitis
history
Nephrolithiasis
or
Urolithiasis
Especially if
Urine Culture
with
Proteus
,
Klebsiella
,
Pseudomonas
(associated with
Struvite Stone
s)
Multi-drug resistant organisms
Persistent symptoms and bacteriuria despite 2 weeks of culture directed antibiotics
Pneumaturia
or fecaluria
Urine Culture
with anaerobic organisms (except
E. coli
,
Staphylococcus
)
Recurrent or treatment-resistant
Pyelonephritis
Voiding dysfunction
Urinary obstructive symptoms
Increased post-void
Residual Volume
Urinary Incontinence
Management
Urinary Tract Infection
Treatment
See
Urinary Tract Infection
for acute management
First-line agents (less likely to induce
Antibiotic Resistance
)
Trimethoprim-sulfamethoxazole or
Septra
,
Bactrim
(3 days)
Nitrofurantoin
or
Macrobid
(5 days)
Fosfomycin or monurol (1 day)
Other agents
Reserve
Fluoroquinolone
s (e.g.
Ciprofloxacin
,
Levofloxacin
) for more complicated infections
Beta lactam agents (
Penicillin
s,
Cephalosporin
s) are less effective in Recurrent UTI
Precautions
Treat uncomplicated cystitis with three day course
Outside pregnancy, avoid treating asymptomatic residual bacteriuria after treatment
Treat uncomplicated cystitis in
Diabetes Mellitus
with same agents as those without diabetes
Urology
Consultation
indications
Hematuria
without
Dysuria
Serum Creatinine
increased
Recurrent
Proteus
infections
Urinary Retention
and
Incontinence
Management
Antibiotic self-starting regimen for symptomatic UTI
Emergency prescription available to start after onset of classic
Urinary Tract Infection
symptoms
Self diagnosis based on
Dysuria
,
Urinary Frequency
, urinary hesitancy is 85% accurate
Choose a 3 day antibiotic course
See
Urinary Tract Infection
for antibiotic options and dosing
Indications for medical evaluation
Symptoms last more than 48 hours despite antibiotics
Fever
Nausea
or
Vomiting
Acute back pain
Vaginal Discharge
Pelvic Pain
STD Exposure
Contraindications
Prior urogenital surgery
Bladder Catheterization
References
Schaeffer (1999) J Urol 161(1):207-11 +PMID:10037399 [PubMed]
Management
UTI Prophylaxis in women
Indications
Recurrent Urinary Tract Infections occurring 3 or more times annually
Continuous UTI Prophylaxis (Average Course: Taken daily for 6 months, up to 12 months)
Preferred first-line continuous prophylaxis (choose one)
Nitrofurantoin
50-100 mg once daily
Trimethoprim Sulfamethoxazole
40/200 daily or three times per week
Other agents used for continuous prophylaxis (choose one)
Trimethoprim 100 mg daily
Cephalexin
125-250 mg daily
Gene
rally avoid for continuous prophylaxis (risk of increasing resistance)
Ciprofloxacin
125 mg daily
Norfloxacin
200 mg daily
Postcoital Prophylaxis
Precaution: Recurrence is common after stopping prophylaxis
One dose taken within 2 hours of intercourse
Preferred first-line post-coital prophylaxis (choose one)
Nitrofurantoin
100 mg once
Trimethoprim Sulfamethoxazole
40/200 to 80/400 once
Other agents used for post-coital prophylaxis (choose one)
Trimethoprim 100 mg once
Cephalexin
250 mg once
Gene
rally avoid for post-coital prophylaxis (risk of increasing resistance)
Ciprofloxacin
125 mg once
Norfloxacin
200 mg once
Post-menopausal women
Topical Estrogen
for
Atrophic Vaginitis
Estriol Cream 0.5 mg intravaginal daily for 2 weeks initially, then twice weekly
Perotta (2008) Cochrane Database Syst Rev (2):CD005131 +PMID:18425910 [PubMed]
Management
Other prophylactic agents
Methenamine
Dose: 1 g orally twice daily
Preparations
Methenamine Hippurate
Methenamine Mandelate
Indications
Short term prophylaxis in patients without renal tract abnormalities
References
Weidner (2018)
Email
communication, received 9/1/2018
Lee (2012) Cochrane Database Syst Rev (10): CD003265 +PMID: 23076896 [PubMed]
Cranberry Juice (variable evidence)
Mechanism
Contains proanthocyanidin compounds
Inhibits
E. coli
from adhering to urinary tract
Recommended daily dosing of cranberry juice
Cranberry extract 300-400 mg tablet bid or
Pure cranberry unsweetened juice 8 ounces tid
Efficacy
No high quality evidence for significant benefit
Guay Drugs (2009) 69(7):775-807 [PubMed]
Not effective in older women living in
Nursing Home
s
Juthani-Mehta (2016) JAMA 316(18):1879-87 +PMID: 27787564 [PubMed]
Daily cranberry juice may decrease recurrent symptomatic UTIs in women over 1 year
Jepson (2008) Cochrane Database Syst Rev (1):CD001321 +PMID:18253990 [PubMed]
Older, original studies suggesting more broad efficacy in UTI prevention
Kontiokari (2001) BMJ 322:1571-3 [PubMed]
Howell (1998) N Engl J Med 339(15): 1085-86 [PubMed]
Lynch (2004) Am Fam Physician 70(11): 2175-77 [PubMed]
Prevention
Behavior Modification
Measures that may offer benefit
Women should empty
Bladder
before and after intercourse
Avoid
Contraceptive Diaphragm
Avoid spermacide
Increased hydration (1.5 extra Liters/day)
Hooton (2018) JAMA Intern Med 178(11):1509-15 [PubMed]
Measures NOT found to reduce UTI risk
Women wiping perineum front to back after stooling
Cotton underwear
Reduced exposure to hot tubs
Reduced use of tampons
Avoid douching (did not decrease UTI risk, but should be avoided due to other risks)
Glover (2014) Urol Sci 25(1): 1-8 [PubMed]
References
Arnold (2016) Am Fam Physician 93(7): 560-9 [PubMed]
Gupta (2013) BMJ 346:f3140 [PubMed]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4688544/
Kodner (2011) Am Fam Physician 82(6): 638-43 [PubMed]
Sen (2006) Clin Evid 15:2558-64 [PubMed]
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