Urinary infection, cystitis

Dr Laurent Vaucher

Urologist, Clinique de Genolier

May 10, 2021

UTI is a general term for any infection of the urinary tract. UTIs are divided into upper (kidney and ureters) and lower (bladder and urethra) infections and simple UTIs are differentiated from complicated UTIs. Any infection associated with an abnormal structure of the genitourinary tract, or the presence of an underlying disease, is considered complicated. Uncomplicated lower urinary tract infection remains one of the most common infections treated by primary care physicians. 40% of women develop a UTI at some point in their life, and adult women are 30 times more likely than men to develop a UTI. This article discusses uncomplicated UTIs in women, with special attention to UTIs in postmenopausal women.

 

DIAGNOSTIC

The diagnosis of acute uncomplicated cystitis can be made on the basis of symptoms (pain, frequency, and urgency). The urine dipstick analysis is the first proposed review. Urine culture is recommended when:

        • suspected pyelonephritis

        • symptoms that do not go away or come back within 2 to 4 weeks following the end of treatment

        • women with atypical symptoms

        • pregnant women

        • male patients with suspected urinary tract infection

It is important to take prostate infections and sexually transmitted infections into account. However, a detailed description of these infections goes beyond the part of this article.

TREATMENT

E. coli is the pathogen most frequently isolated in urinary tract infections. Other uropathogens include Staphylococcus saprophyticus, Enterococcus, Klebsiella, Enterobacter and Proteus. For patients with uncomplicated non-febrile urinary tract infections, pain control and minimal use of antibiotics should be a priority. The cystitis can be a self-limiting disease. Therefore, pain relievers are a good option for treating symptoms and reducing pain. consumption of antibiotics. Simple cystitis, however, responds very well to oral antibiotics. The first choice antibiotic treatment is currently Fosfomycin and Nitrofurantoin. These antibiotics are rapidly excreted in the urine and are hardly present in the tissues, which makes it an excellent choice for acute cystitis.

Cotrimoxazole (Bactrim®) is classically used to treat urinary tract infections, however, the resistance of Escherichia coli to this drug has increased markedly over the past decades, currently reaching 15-30%. Resistance of urinary pathogens fluoroquinolones (Ciproxine ®, Noroxine ®) is also very high, and the latter is no longer recommended as first-line therapy.

RECURRENT URINARY TRACT INFECTION

Recurrent UTIs are symptomatic infections that follow the resolution of a previous episode, usually after appropriate treatment. They can occur in women of all ages. The bacteria from the initial infection and the re-infecting agent are usually the same. In postmenopausal women, estrogen deficiency is a risk factor for recurrent urinary tract infection. Hereditary factors also appear to influence susceptibility to recurrent urinary tract infections.

In women with recurrent UTIs, imaging of the upper urinary tract and cystoscopy are not routinely recommended. However, they should be done without delay in patients who have a recurrence immediately after the end of the antibiotic treatment, or when there is blood in the urine after the infection resolves. Indeed, the possibility that a malignant tumor is causing persistent and unresolved symptoms should be excluded.

PROPHYLACTIC TREATMENTS

Antibiotic
Candidates for prophylactic antibiotic treatment should have at least one positive urine culture to confirm the concordance of symptoms with true infection. The optimal duration of antibiotic prophylaxis is unknown. Based on a consensus and limited data, an initial course of 3 to 12 months should be offered.

Non-antibiotic
Trying to use an analgesic or anti-inflammatory drug for the treatment of symptoms may limit the use of antibiotics in some patients. Prophylaxis with a cranberry product may limit the recurrence of urinary tract infections. Cranberries contain proanthocyanidins that may prevent E. coli from sticking to bladder cells. The data is contradictory as to their effectiveness. It is, however, a simple, low-risk intervention that can help reduce episodes of infection and the use of antibiotics.

Although the specific mechanisms are still poorly understood, estrogen plays a key role in regulating the natural defense of the lower urinary tract against infection. In postmenopausal women, treatment with topical estrogen may reduce the recurrence rates of urinary tract infections through their effects on the vaginal flora.

Studies on intra-vaginal and oral probiotics of Lactobacillus, the Oral d-mannosis, acupuncture, and immunoprophylactic regimens are rare and contradictory, and further studies are needed.

ASYMPTOMATIC BACTERIURIA

Asymptomatic bacteriuria (presence of bacteria in the urine) is very common in the elderly, and also occurs in about 1 to 5% of healthy premenopausal women. It does not cause kidney disease or damage, and treatment of asymptomatic bacteriuria is therefore not recommended in patients without risk factors.

More sensitive diagnostic tests have recently shown that urine is not sterile. The urinary tract is inhabited by a urinary microbiota (microbial population) unique. Bacteriuria represents a fraction of the various microbiota housed in the urinary tract. These bacterial communities are generally beneficial and necessary for local balance. If all the microbes residing in the urinary tract human is identified in the near future, some treatments for urinary tract infections by antibiotics could turn into a correction of the imbalance. Thanks to this research, we should be able to better define the patients who really need antibiotics.

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