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Acute cystitis in women is typically uncomplicated and amenable to empiric antimicrobial therapy. We advocate a simple approach, in which women with uncomplicated cases are treated over the telephone. Such a program has been in place at the Cleveland Clinic since 1992, and has yielded good results.
Urinary tract infection is one of the most common medical complications of pregnancy, occurring in roughly 10% of all pregnancies. The clinical entities most commonly seen are bacteriuria, acute cystitis, and acute pyelonephritis. Relative stasis of urine due to pregnancy-induced changes in the urinary tract is a significant causative factor. Escherichia coli is the most common responsible organism. Patients with untreated or inadequately treated asymptomatic bacteriuria are at high risk for development of acute pyelonephritis, a serious febrile illness that can lead to major maternal and fetal complications. Patients with acute pyelonephritis should be hospitalized and treated aggressively.
BACKGROUND: Uncomplicated acute cystitis is one of the most common bacterial infections in adults. The percentage of women who have at least one episode of acute cystitis is estimated to be between 40% to 50%. Quinolones are recommended for acute cystitis in regions where the level of resistance to other antimicrobials namely co-trimoxazole is high. However the efficacy, safety and tolerance of quinolones needs investigation. OBJECTIVES: To compare the efficacy, safety and tolerance of different quinolones in women with uncomplicated acute cystitis. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library Issue 3, 2003), MEDLINE (1966 - September 2003), EMBASE (1988 - September 2003), reference lists of articles and abstracts from conference proceedings without language restriction. Reference lists of urology, infectious diseases and nephrology textbooks, review articles and relevant studies. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing two or more different quinolones in women (>/= 16 years) with uncomplicated acute cystitis were selected. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes with 95% confidence intervals (CI). MAIN RESULTS: We identified 11 studies enrolling 7535 women. There were no significant differences in clinical or microbiological efficacy between quinolones. Photosensitivity reactions were more frequently observed for sparfloxacin when compared to ofloxacin. Any adverse event, adverse events causing withdrawal, skin adverse events, photosensitivity reactions were more common for lomefloxacin when compared to norfloxacin. Any adverse event, adverse drug reactions, CNS adverse events were more common for ofloxacin when compared to ciprofloxacin. CNS adverse events and insomnia were more often reported for rufloxacin when compared to pefloxacin. Adverse drug reactions occurred frequently for ofloxacin than levofloxacin. Insomnia was reported more frequently for enoxacin than ciprofloxacin. AUTHORS' CONCLUSIONS: We found no significant differences in clinical or microbiological efficacy between quinolones but some differences in occurrence and spectrum of quinolone safety.
Uncomplicated acute cystitis, defined as acute lower urinary tract infection in an otherwise healthy, non-pregnant, adult woman, is the most frequent form of urinary tract infection managed in general practice. The current views on diagnosis and treatment are reviewed. Using clinical epidemiological concepts we focus on the importance of the medical history, but urinalysis can be regarded as an aid in the process of differential diagnosis. Most patients will be cured by a three-day oral course of antibiotic treatment. Longer duration of treatment gives no increase in the rate of cure, and a higher rate of side-effects. Several antibiotics may be used, and from an ecological point of view we encourage a varied prescription policy. No follow-up is needed unless the symptoms persist or reappear soon after treatment.
UNLABELLED: Short courses of antibiotics are often recommended to treat children with acute cystitis despite lack of firm evidence to support such management. The aim of this study therefore was to analyse the short-term outcome of such treatment. The retrospective analysis included 300 children (252F, 48M) fulfilling the criteria of first-time acute cystitis and managed according to a protocol recommending 5 d treatment. In 214 (71%) the treatment was given according to the protocol and in the others for 7 or 10 d. Nitrofurantoin was used in 150 (50%) and trimethoprim without or with sulfonamide in 129 (43%). The short-term results were excellent with 96% of the children being free from symptoms at the first follow-up visit after a median of 6 d. Only 2 girls had persisting bacteriuria and thus the frequency of bacteriological treatment failure was 1%. Recurrence within 30 d occurred in 4 girls (2%). CONCLUSION: A 5 d treatment with antibiotics is adequate in children with acute cystitis. Routine follow-up visits after a first acute cystitis may not be necessary, providing that the bacteria causing the infection are sensitive to the prescribed antibiotic and that there is no history of defective bladder or bowel emptying.
BACKGROUND: Guidelines for the management of acute cystitis support empirical antibiotic treatment; however, up to half of symptomatic women have negative urine cultures. OBJECTIVE: To determine whether empirical treatment leads to unnecessary antibiotic prescriptions in women with symptoms of acute cystitis. METHODS: A cohort of 231 women (defined as females aged 16 years and older) presenting to family physicians' offices with symptoms of cystitis underwent a standardized clinical assessment, urine dip testing, and culture. Recommendations for urine testing and antibiotic treatment under 3 empirical strategies were compared with observed physician management and a logistic regression model for the outcomes of antibiotic prescriptions, urine culture testing, and unnecessary antibiotics, defined as a prescription where the subsequent urine culture was negative. RESULTS: There were 123 positive urine cultures (53.3%). Physicians prescribed antibiotics to 186 women (80.9%), of whom 74 (39.8%) were culture negative. Unnecessary antibiotic use was similar for 2 guidelines recommending empirical antibiotic treatment without testing for pyuria (41.4% and 40.6%). Treating women with classic cystitis symptoms and pyuria would have decreased unnecessary antibiotic use (26.2%; P =.02) but resulted in fewer women with confirmed urinary tract infection receiving immediate antibiotics (66.4% vs 91.8% usual care; P<.001). A derived prediction model incorporating testing for pyuria and nitrites would also have reduced unnecessary antibiotic use (27.5%; P =.03), but more women with confirmed urinary tract infection would have received immediate antibiotics (81.3%; P =.01). CONCLUSIONS: Empirical antibiotic treatment of acute cystitis in women without testing for pyuria promotes unnecessary antibiotic use. A simple decision rule provides for prompt treatment of infected women while reducing antibiotic overuse and unnecessary urine testing.
INTRODUCTION AND OBJECTIVE: Acute cystitis is the most frequent symptomatic infection in females and the urological condition which results in more visits to the clinic. The empirical treatment commonly instituted requires a continuous update of local microbial susceptibility to keep resistance emergence under control and reduce costs. Our goal was to study the current susceptibility of all urological pathogens isolated in acute cystitis in female patients. MATERIAL AND METHODS: Prospective study on 218 cases of acute cystitis in females reported between March 2000 and November 2000 in Health Centres within our Health Care Area. Patients were distributed by age range also including other parameters such as history of previous cystitis and predisposing factors, clinical sings and symptoms, as well as isolated micro-organisms and their "in vitro" susceptibility and MIC (Minimum Inhibitory Concentration) against the anti-microbial agents most commonly used in the clinical practice. RESULTS: The larger age groups were 25-35 and 65-75 years. 162 cases were intermittent and 56 were repeat cystitis. Haematuria was present in 14% cases. The microbial spectrum was similar in all groups; overall E. coli was isolated in 82.1% cases, K. pneumonia in 6%, S. agalactiae 3.7%, E. faecalis 2.3%, P. mirabilis 1.8% etc. Resistance rates for E. coli were: 0.6% for cefixime, 1.1% for amoxycillin-clavulanate, 1.7% tobramycin, 2.8% fosfomycin, 3.3% nitrofurantoin, 18.4% ciprofloxacin, 19.6% norfloxacin, 22.3% pipemidic acid, 35.8% co-trimoxazol and 54.7% ampicillin. Repeat cystitis was more frequent in patients over 65 years with higher resistance rates mainly in the quinolones group (28.6% ciprofloxacin and 30.4% norfloxacin for E. coli). Mean MIC for ciprofloxacin with regard to E. coli was: 1.503 mcg/mL (range: 0.06-8) and 3.96 mcg/mL (range: 1-16) for amoxycillin-clavulanate. CONCLUSION: High E. coli resistance rates to quinolones are still persistent. Excellent susceptibility to amoxycillin-clavulanate, cefixime and aminoglycosides, which allows for their use in short-term treatment regimes. High resistance rates to urinary antiseptic agents such as co-trimoxazol and ampicillin, and low rates for agents such as fosfomycin and nitrofurantoin.
BACKGROUND: Although acute cystitis is a common infection in women, the impact of this infection and its treatment on women's quality of life (QOL) has not been previously described. OBJECTIVES: To evaluate QOL in women treated for acute cystitis, and describe the relationship between QOL, clinical outcome and adverse events of each of the interventions used in the study. METHODS DESIGN: Randomized, open-label, multicenter, treatment study. SETTING: Two family medicine outpatient clinics in Iowa. PATIENTS: One-hundred-fifty-seven women with clinical signs and symptoms of acute uncomplicated cystitis. INTERVENTION: Fifty-two patients received trimethoprim/sulfamethoxazole 1 double-strength tablet twice daily for 3 days, 54 patients received ciprofloxacin 250 mg twice daily for 3 days and 51 patients received nitrofurantoin 100 mg twice daily for 7 days. MEASUREMENTS: QOL was assessed at the time of enrollment and at 3, 7, 14 and 28 days after the initial visit. QOL was measured using a modified Quality of Well-Being scale, a validated, multi-attribute health scale. Clinical outcome was assessed by telephone interview on days 3, 7, 14 and 28 using a standardized questionnaire to assess resolution of symptoms, compliance with the prescribed regimen, and occurrence of adverse events. RESULTS: Patients experiencing a clinical cure had significantly better QOL at days 3 (p = 0.03), 7 (p < 0.001), and 14 (p = 0.02) compared to patients who failed treatment. While there was no difference in QOL by treatment assignment, patients experiencing an adverse event had lower QOL throughout the study period. Patients treated with ciprofloxacin appeared to experience adverse events at a higher rate (62%) compared to those treated with TMP/SMX (45%) and nitrofurantoin (49%), however the difference was not statistically significant (p = 0.2). CONCLUSION: Patients experiencing cystitis have an increase in their QOL with treatment. Those experiencing clinical cure have greater improvement in QOL compared to patients fail therapy. While QOL is improved by treatment, those reporting adverse events have lower overall QOL compared to those who do not experience adverse events. This study is important in that it suggests that both cystitis and antibiotic treatment can affect QOL in a measurable way.
Acute cystitis is one of the commonest medical problems encountered by primary care physicians. It affects more women than men (8:1), but the incidence among men is increasing. Uncomplicated cystitis by definition occurs in healthy patients with a normal urinary tract, whereas complicated cystitis implies a predisposing or underlying condition. A narrow range of aetiological agents is responsible for most uncomplicated cystitis in women (Escherichia coli in 80% of cases). Recently, however, pathogens usually associated with sexually transmitted disease have been implicated. In women with typical symptoms of acute uncomplicated cystitis, an abbreviated laboratory work-up followed by empirical therapy is recommended. Single-dose and 3 day regimens of co-trimoxazole and the quinolones are as effective as longer regimens and have a higher eradication rate than other commonly used antimicrobials. Relapse rates are slightly higher with single-dose therapy. With this success rate plus the reduced cost and improved patient compliance, these regimens have replaced traditional 5 to 14 day courses of treatment. With increasing resistance of the common urinary pathogens to amoxycillin and, now, co-trimoxazole, the quinolones are a logical choice for empirical therapy of uncomplicated urinary tract infections.
BACKGROUND: A high prevalence of antimicrobial resistance among urinary isolates in the Garhwal region of Uttaranchal. AIMS: To identify the most appropriate antibiotic for empirical treatment of community-acquired acute cystitis on the basis of local antimicrobial sensitivity profile. SETTINGS AND DESIGN: A prospective clinico-microbiological study including all clinically diagnosed patients with community acquired acute cystitis attending a tertiary care teaching hospital over a period of three years. METHODS AND MATERIAL: Clean-catch midstream urine specimens, from 524 non-pregnant women with community-acquired acute cystitis, were subjected to semi-quantitative culture and antibiotic susceptibility by the Kirby- Bauer disc diffusion method. A survey was also conducted on 30 randomly selected local practitioners, to know the prevalent prescribing habits in this condition. STATISTICAL ANALYSIS: The difference between the susceptibility rates of E. coli isolates to Nitrofurantoin and the other commonly prescribed antibiotics was analysed by applying the z test for proportion. RESULTS: 354 (67.5%) specimens yielded significant growth of E. coli.> 35% of the urinary E.coli isolates were resistant to the fluoroquinolones, which were found to be the most commonly used empirical antibiotics in acute cystitis. Resistance was minimum against Nitrofurantoin (9.3%, 33) and Amikacin (11.0%,39).> 80% of the fluoroquinolone-resistant strains were found to be sensitive to Nitrofurantoin. CONCLUSION: The best in vitro susceptibility profile in our study has been shown by Nitrofurantoin and a significantly high proportion of the urinary E. coli isolates have already developed resistance to the currently prescribed empirical antibiotics, viz. the fluoroquinolones. In view of these in vitro susceptibility patterns, a transition in empirical therapy appears imminent.
In a randomised, double blind, long term, crossover study 1 g twice daily of methenamine hippurate was compared with placebo for its preventive effect on recurrent attacks of acute cystitis. Methenamine hippurate and placebo were interchanged every six months for two years. During one of the years patients took 250 ml extra fluid every morning and evening. Out of 21 enrolled patients, 14 completed the first year and 13 both years of treatment, which permitted the evaluation of 27 patient years. There were 52 episodes of acute cystitis caused by reinfection: 41 occurred during placebo treatment and only 11 during the methenamine hippurate regimen (p less than 0.01). Extra fluid intake did not reduce the incidence of acute cystitis, nor did it reduce the effect of methenamine hippurate. Methenamine hippurate is an effective prophylactic agent against recurrent acute cystitis and has the advantage of not inducing cross resistance to conventional antibiotics.
Ofloxacin (OFLX) was administered to 236 female patients with acute cystitis. Of them 164 patients who satisfied the criteria proposed by the UTI Committee, Japan were examined for the efficacy of the treatment, but all cases were included in the study of the side effects of the drug. In the 65 patients who received 300 mg (3 divided doses) of OFLX per day, the overall clinical efficacy was excellent in 66.2% and moderate in 33.8% of the patients. In the 99 patients who received 600 mg (3 divided doses) of OFLX per day, the overall clinical efficacy was excellent in 79% (P less than 0.076) and moderate in 18.2% of the patients. No failure of the treatment was observed in the two groups. Of 164 bacterial strains isolated from the urine of the patients, 132 strains were identified as E. coli. All bacterial strains were eradicated in the urinary specimens by the treatment. Subjective side effects were observed in 8 (3.4%) of the 236 patients. Gastrointestinal disturbance was complained by 6 patients. No drug-related aggravation in the laboratory test was observed except for one patient who showed mild leukopenia reduced from 3700/mm3 to 2200/mm3. These results showed that the oral administration of OFLX was excellent and satisfactory in the treatment for acute cystitis.
Thirty six female patients with acute cystitis were treated with one shot intravenous injection of 1 g cefminox. Clinical efficacy was evaluated based on extent of subjective symptoms, pyuria and bacteriuria. Of 36 patients, an excellent efficacy was shown in 32 cases, moderate in 3 cases and poor in 1 case. This poor case was diagnosed as complicated urinary tract infection because of right vesicoureteral reflux. Therefore, the overall effectiveness rate of this treatment for acute uncomplicated cystitis in women was 100%. Single dose chemotherapy with an adequate antibiotic is considered a useful treatment for female acute cystitis.
One hundred sixty-three women with uncomplicated acute lower urinary tract infections were included in a multicenter randomized study comparing cefpodoxime-proxetil (one 100-mg tablet twice daily) with trimethoprim-sulfamethoxazole (one double-strength tablet [160/800 mg] twice daily) for 3 days. A total of 30 women in both arms were excluded from the study for various reasons. At 4 to 7 days after the discontinuation of therapy, 62 of 63 (98.4%) cefpodoxime-proxetil recipients and 70 of 70 (100%) trimethoprim-sulfamethoxazole patients were clinically cured and demonstrated bacteriological eradication, respectively. At 28 days after treatment, 48 of 55 (87.3%) and 43 of 50 (86%) cefpodoxime-proxetil recipients as well as 51 of 60 (85%) and 42 of 50 (84%) trimethoprim-sulfamethoxazole recipients were clinically cured and demonstrated bacteriological eradication, respectively. Independently of the prescribed regimen, a significant difference (P < 0.001) in failure rates was observed only for patients with a previous history of three or more episodes of acute cystitis per year. With the exception of one patient in the trimethoprim-sulfamethoxazole arm who discontinued therapy because of gastrointestinal pain, both antimicrobials were well tolerated. In conclusion, cefpodoxime-proxetil treatment for 3 days was as safe and effective as trimethoprim-sulfamethoxazole for 3 days for the treatment of uncomplicated acute cystitis in women.
OBJECTIVES: A multicentric double-blind double-placebo randomized trial was conducted to compare the effectiveness and safety of ciprofloxacin versus pefloxacin given in a single oral dose in female out-patients with acute cystitis. METHODS: A series of 561 female patients (age range 18-65 years) with signs of uncomplicated community acquired acute cystitis were randomly assigned to parallel groups given a single oral dose of ciprofloxacin (500 mg + placebo) or pefloxacin (800 mg + placebo). Clinical and bacteriological effectiveness was evaluated 12 +/- 2 days after the treatment day. RESULTS: The clinical outcome was equivalent for the two groups (92 vs 88.9% clinical cure for ciprofloxacin and pefloxacin respectively). Mean time to clinical resolution was about 40 hours in both groups. Urine sterilization was comparable in the two groups (80.8 and 81.1% respectively). Undesirable side effects (mostly digestive tract disorders and neurosensorial complaints) were reported in 16.1% of the patients taking ciprofloxacin and 18.1% of those taking pefloxacin (NS). Single-dose treatment was well accepted by 82.3 and 84.8% of the women respectively. CONCLUSION: These findings demonstrate that ciprofloxacin and pefloxacin are equally effective and equally well tolerated as single-dose oral curative therapy for acute cystitis in women.
Vaginal colonization with Escherichia coli is an integral step in the development of acute cystitis, and persistent vaginal coliform colonization may also be a predisposing step to recurrent urinary tract infections. For this reason, we evaluated antibiotic concentrations in the vaginal fluid, serum, and urine and the vaginal colonization by E. coli of 56 women receiving either ofloxacin (200 mg orally twice a day) or trimethoprim-sulfamethoxazole (TMP-SMX) (160/800 mg orally twice a day) for the treatment of acute cystitis. Ofloxacin and trimethoprim both penetrated into vaginal fluid to a considerably greater extent than sulfamethoxazole. Among 33 patients given ofloxacin, the concentration of the drug in vaginal fluid during one dosage interval ranged from 1.6 to 21.6 micrograms/ml. In 21 women given TMP-SMX the range of drug concentrations in vaginal fluid was 2.6 to 32.5 micrograms/ml for TMP and 1.0 to 6.2 micrograms/ml for SMX. Treatment with both ofloxacin and TMP-SMX remarkably reduced vaginal colonization by E. coli during and up to 30 days after therapy. For the ofloxacin-treated women, eradication of vaginal E. coli was associated with a high ratio of drug concentration in vaginal fluid to that in serum. We conclude that ofloxacin and TMP both achieve high concentrations in vaginal fluid and are equally successful in eradicating E. coli from the vagina.
Empirical antimicrobial treatment for acute cystitis in women requires continuing reassessment as the antimicrobial susceptibility of community isolates of Escherichia coli evolves. Current recommendations for 3 days trimethoprim or trimethoprim/sulphamethoxazole are compromised by increasing resistance of community E. coli to these agents. Fluoroquinolones are an alternate 3-day therapy, but increasing resistance is being reported from some countries, and widespread community use may promote resistance, limiting effectiveness of these agents for more serious infections. Alternate regimens supported by recent clinical trials suggest pivmecillinam given twice daily for 7 days is as effective as 3 days of quinolone therapy, while microbiological cure is 80% with 3 days therapy twice daily, and 90% with 3 days therapy thrice daily. Nitrofurantoin given for 7 days has a cure rate of 80-85%. Fosfomycin trometamol as a single dose has cure rates of 75-85%. All these agents are effective, but a compromise in efficacy or duration of therapy compared with current 3-day regimens may have to be considered.
Single dose treatment regimens (SDT) are effective, inexpensive alternatives to longer courses of therapy for adult females with acute cystitis or asymptomatic bacteriuria. A number of SDT regimens consistently cure 85 to 100% of women with acute cystitis and 50 to 80% of women with asymptomatic bacteriuria. However, SDT is inherently less effective than longer regimens because many upper tract infections are not cured. Initial SDT studies suggested that most patients with significant renal invasive disease or underlying urological abnormalities fail therapy. As a result, SDT has been proposed as an efficient strategy to diagnose significant upper tract infections with accompanying pathology that merit additional investigation or treatment. Few studies have refuted or supported this hypothesis. Single-dose treatment studies show an association between the site of infection as determined by the antibody-coated bacteria (ACB) test and treatment outcome. Patients with ACB-negative tests have a cure rate of over 90% in almost all studies in which the organism is susceptible to the agent chosen. Patients with positive ACB tests tend to have treatment failure rates of 30 to 50%. However, imaging studies have not been carried out in parallel with these studies and the validity of using single-dose treatment failure to screen women for significant upper tract pathology has still not been established.