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Acute cystitis

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Updated 2024 EAU guidelines for the diagnosis and management of acute cystitis.

Background

Overview

Definition
Acute uncomplicated cystitis is a lower UTI occurring in the absence of anatomic or functional abnormalities of the urinary tract or any other complicating factors.
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Pathophysiology
Acute uncomplicated cystitis is mostly caused by bacteria, including E. coli (86%), S. saprophyticus (4%), Klebsiella species (3%), Proteus species (3%), Enterobacter species (1.4%), Citrobacter species (0.8%), and Enterococcus species (0.5%).
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Disease course
Bacterial infection of the lower urinary tract results in acute uncomplicated cystitis, which causes classic symptoms of dysuria, frequent voiding of small volumes, and urinary urgency. Occasional hematuria and suprapubic discomfort may be present.
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Prognosis and risk of recurrence
Acute uncomplicated cystitis is not associated with an increase in mortality.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute cystitis are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the European Association of Urology (EAU 2024), the American College of Obstetricians and Gynecologists (ACOG 2023), the Infectious Diseases Society of America (IDSA 2022,2016), the American College of Physicians (ACP ...
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Screening and diagnosis

Etiology
As per GUS 2018 guidelines:
Recognize that the most common cause of uncomplicated UTIs is E. coli, followed by S. saprophyticus, K. pneumoniae, and P. mirabilis. Recognize that other pathogens are rare.
A
Recognize that Enterococci are most commonly found in mixed infections, therefore, their pathogenicity is uncertain in uncomplicated UTIs.
B
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  • Diagnostic criteria

  • Differential diagnosis

Classification and risk stratification

Severity assessment: as per GUS 2018 guidelines, use the Acute Cystitis Symptom Score to assess the severity of symptoms, the course of the disease over time, and the effect of therapy.
B

Diagnostic investigations

History and physical examination: as per GUS 2018 guidelines, obtain a symptom-related medical examination with clinical examination in the first presentation of acute UTI or if the patient is unknown to the physician.
B

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  • Urine dipstick

  • Urine culture

  • Urethrocystoscopy

  • Diagnostic imaging

Medical management

Antibiotic therapy, general principles: as per AAFP 2024 guidelines, consider prescribing a backup antibiotic (to be filled if symptoms do not improve within 48-72 hours or worsen at any time) in female patients with no signs of pyelonephritis or complicated infection not wishing to take antibiotics.
C

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  • Antibiotic therapy (first-line therapy)

  • Antibiotic therapy (second-line therapy)

  • Symptomatic management

Nonpharmacologic interventions

Fluid intake: as per AAFP 2024 guidelines, advise drinking at least 1.5 L of fluids daily in patients with a UTI.
B

Specific circumstances

Pregnant patients, evaluation: as per EAU 2024 guidelines, obtain urine culture in pregnant patients with suspected acute cystitis.
A

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  • Pregnant patients (management)

  • Patients with antimicrobial-resistant UTI

  • Patients with Candida UTI

Preventative measures

Periprocedural antibiotic prophylaxis: as per EAU 2024 guidelines, do not use antibiotic prophylaxis to reduce the rate of symptomatic urinary infection following urodynamics, cystoscopy, or extracorporeal shockwave lithotripsy.
D
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Follow-up and surveillance

Post-treatment surveillance: as per SEIMC 2017 guidelines, do not obtain routine post-treatment cultures in asymptomatic female patients following treatment for cystitis.
D