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

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).

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.

1. Hooton TM, Gupta K. Acute simple cystitis in women. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2020.

   
   

2. Rodriguez-Bano et al. Community infections caused by extended-spectrum B-lactamase-producing Escherichila coli. Arch Intern Med. 2008;168(17):1897-1902.

   
   

3. Long B, Koyfman A. The emergency department diagnosis and management of urinary tract infection. Emerg Med Clin North Am. 2018;36:685-710.

   
   

4. Spectrum App

   
   

5. Kurtz M et al. Etiology and evaluation of hematuria in adults. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2020.