tinkle tinkle...

This post is a quick notes version regarding cystitis/pyelonephritis:

DYSURIA with vaginal irritation correlates with a > 90% diagnosis of cystitis. This can occur with a NORMAL urinalysis.

Yeah, I know there are dipstick tests and what not, and the overall specificity and sensitivity is okay, but if you have a patient that gives a correlating history it's still cystitis.

cystitis vs. pyelonephritis, what's the difference?
Classic S/Sx of pyelonephritis:
fever
n/v
CVA tenderness

Remember, PYELONEPHRITIS A CLINICAL DIAGNOSIS!!! You can have a patient who is afebrile, non-toxic appearing that complains of flank pain, positive U/A. You can diagnose as pyelonephritis.

U/A (catheter specimen if female on menses). Let's narrow down on the pertinent results:
1) Urine RBC
2) Urine WBC
- Pyuria (the most specific finding!)
- must be >10
4) Urine Leukocytes
- size of WBC, doesn't mean much.
3) Urine Nitrites
- Positive nitrites is HIGHLY specific!! Odds are you have Pseudomonas, Enterococcus, or Acinetobacter.
4) Squamous Epithelium
- Squamous epithelium....so annoying. If you have any concerns of pyelonephritis, get a catheter specimen.
5) Urine Bacteria
6) Urine pregnancy

DO NOT FORGET TO SEND THE URINE FOR A CULTURE. 

Renal Function to r/o acute renal failure:
BUN/Cr
GFR


CBC r/o sepsis:
WBC
H/H


REMEMBER, think about urine in the ELDERLY with a fever of unknown origin, or altered mental status.

Literature states asymptomatic catheter associated UTI do not require treatment.

What about incidental findings? asymptomatic bacturia (no fever, suprapubic tenderness) is only treated during PREGNANCY!!

Differential:
PID- Unfortunately suprapubic pain will warrant a pelvic exam.
vaginitis
urethritis

If the patient continues to have symptoms after 48 hours of antibiotic treatment, CT ABD/PELVIS to r/o anatomic anomalies, obstructed stone, papillary necrosis, abscess.
If there is hematuria and flank pain, get a CT ABD/PELVIS. 

Treatment:
Simple cystitis (no concerns for pyelonephritis, no pyuria)
TMP-SMX (Bactrim)160/800mg BID x 5 days if a good first choice for simple cystitis (no concerns for pyelonephritis).

Nitrofurantoin (Macrobid) 100mg BID x 5 days is another good choice for simple cystitis (and for asymptomatic preggers!)

Complicated cystitis/pyelonephritis (fever, pyuria, CVA tenderness, known anti-biotic resistance, patient already being treated 48-72h):
Ciprofloxacin 500mg BID x 10 days for D/C medication.
Rocephin 1gm IV OR Levaquin 500mg IV once in ED
Remember this is the ED, the mindset will be assume the worst.

Side note: I highly suggest you look at your nearest medical center's antibiogram before giving antibiotics. You'd be surprised what you find.

When to admit:
Altered mental status
intractable vomiting
pregnancy
Sepsis, shock, acute renal failure, blah blah blah.

References:
Cline, D.M., Ma, O.J., Cydulka, R.K., Meckler, G.D., Handel, D.A., & Thomas, S.H. (2012). Tintinalli's Emergency Medicine Manual (7th ed.) McGraw Hill Professional: Columbus, OH.

Hooton, TM, Gupta, K. Acute Uncomplicated Cystitis and Pyelonephritis in Women. In: UpToDate, Basow, DS (Ed), UpToDate,Waltham, MA, 2012.

Hooton, TM. Acute Complicated Cystitis and Pyelonephritis. In: UpToDate, Basow, DS (Ed), UpToDate,Waltham, MA, 2012.