Urinary tract infections (UTIs), including cystitis and pyelonephritis, are common. Each year, they account for more than 10 million outpatient visits and more than 3 million emergency department visits. Recurrent UTIs (defined as three in 1 year or two in 6 months) also are common, occurring in 20% to 30% of women. The annual incidence of UTIs is 12.1% among women and 3% among men. Cystitis symptoms include lower abdominal pain, dysuria, and urinary urgency or frequency. Escherichia coli is the most common pathogen. Cystitis often is diagnosed inappropriately when patients have asymptomatic bacteriuria (ie, positive urine culture result without symptoms). This can result in unnecessary antibiotic therapy. For uncomplicated acute cystitis in women, guidelines recommend nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole for 3 days (if local drug-resistance rates are less than 20%), fosfomycin in a single dose, or pivmecillinam for 5 days. Effective prophylactic options for UTI include antibiotics and vaginal estrogen for postmenopausal women. Antibiotics are most effective but are associated with a risk of increased drug resistance. Patients with pyelonephritis present with costovertebral tenderness, fever, and urinary symptoms. Third-generation cephalosporins are preferred for management. Significant complications of pyelonephritis include sepsis or septic shock, obstructive pyelonephritis, emphysematous pyelonephritis, perinephric abscess, and kidney transplant rejection. For pregnant patients with pyelonephritis, hospitalization and intravenous antibiotics are indicated.
Case 4. KR is a 31-year-old patient who comes to your office for a follow-up visit after a recent hospitalization for pyelonephritis. She has had recurrent urinary tract infections (UTIs) since her marriage about 5 years ago. She has tried many prophylactic treatments, such as cranberry juice and probiotics, but the frequent UTIs have persisted. KR has been hospitalized twice for pyelonephritis, with an episode during pregnancy and the episode related to the recent hospitalization.
UTIs, including cystitis and pyelonephritis, are among the most common infections diagnosed in emergency departments, urgent care centers, and primary care settings. Each year, these infections account for more than 10 million outpatient visits and more than 3 million emergency department visits.126,127 They are the third leading cause of infection-related hospitalizations in older adults.128 The annual incidence of UTI is 12.1% among women, with a peak between ages 20 to 24 years. The annual incidence among men is 3% with a peak at older than 85 years.129
Approximately 20% to 30% of women have recurrent UTIs, defined as three in 1 year or two in 6 months.130 Recurrent UTIs can be reinfections with the same organism or infections with different organisms. Among patients with recurrent UTIs, asymptomatic bacteriuria occurs in 5% of premenopausal women, up to 9% of postmenopausal women, 8% of pregnant women, and 100% of patients with indwelling catheters.131,132
Cystitis
CLINICAL PRESENTATION AND DIAGNOSIS
Cystitis is a lower UTI that involves inflammation of the bladder. Clinical symptoms include lower abdominal pain, dysuria, and urinary urgency or frequency. On urinalysis or urine dipstick test results, the presence of nitrites, moderate pyuria (urine white blood cells), and/or bacteriuria is indicative of UTI. The presence of leukocyte esterase and nitrites has a specificity of 98% to 100% for UTI, though the sensitivity is 35% to 84%. A positive urine culture result with greater than 105 colony-forming units/mL is the typically accepted definition of UTI.133
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