Acute Cystitis: Diagnosis and Treatment

Symptoms and urine testing

Acute cystitis is usually a bacterial infection of the bladder. Symptoms include burning or pain when urinating, frequent or urgent urination, a feeling of incomplete emptying, lower abdominal discomfort, cloudy urine and blood in the urine.

We assess symptoms, pregnancy possibility, allergies, previous infections and recent antibiotics. Urinalysis supports the diagnosis; discharge or genital symptoms may suggest another cause, such as vaginitis or urethritis.

Urine culture and antibiotic susceptibility testing

Culture is particularly important for recurrent, atypical or persistent symptoms, suspected resistance, fever, pregnancy and infections in men. Symptoms and routine urinalysis alone cannot identify ESBL-producing bacteria or determine which antibiotic will work. Urine culture and antibiotic susceptibility testing are used to assess this. When culture is needed, we try to collect the sample before antibiotics are started.

Oral antibiotics: options and typical treatment courses

The following examples apply to nonpregnant adult women with acute uncomplicated cystitis and no fever, chills, or back or flank pain. Selection depends on kidney function, allergies, previous cultures, recent antibiotics and local resistance. These examples are drawn from the Japanese JAID/JSC 2015 guideline; the order of preference depends on the organism and patient.

• Prescription example

  Penicillin with a beta-lactamase inhibitor: amoxicillin/clavulanate (Augmentin 250RS; 250 mg/125 mg per tablet), one tablet three times daily for 7 days.

• Prescription example

  Oral cephalosporin example: cefcapene pivoxil (Flomox) 100 mg three times daily after meals for 5–7 days. Oral cephalosporins generally do not cover ESBL-producing bacteria.

• Prescription example

  Levofloxacin (Clavit) is not our first choice for acute uncomplicated cystitis because resistance is increasing. It may be considered when culture and susceptibility testing indicate activity and other antibiotics are unsuitable. The JAID/JSC 2015 example for acute uncomplicated cystitis is 500 mg (one 500-mg tablet) orally once daily for 3 days. Dose and interval are adjusted for kidney function.

• Prescription example

  Fosfomycin (FOM): the Japanese 2015 guideline lists 1 g orally three times daily for 2 days as an option for suspected or confirmed ESBL-producing bacteria. This historical regimen is not a blanket recommendation; use is assessed using culture and susceptibility results and the clinical context.

• Acetaminophen (Calonal) may be used for pain after assessing other conditions and medicines.

During treatment, treatment failure and recurrence

Drink your usual amount of fluid to avoid dehydration, without forcing large amounts, and avoid holding urine for long periods. Follow the prescribed course; do not stop on your own or take leftover antibiotics. Treatment may be adjusted according to culture results and clinical response.

Return if symptoms fail to improve, recur soon after treatment, or if fever or back pain develops. Persistent blood in the urine needs further investigation.

Two episodes in 6 months or three in a year suggest recurrent cystitis. Culture and assessment for factors such as stones, residual urine and postmenopausal changes may be useful; CT and cystoscopy are not required for everyone.

References