Dr. med. Dirk Manski



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Bladder infection (bacterial cystitis): Treatment

Review literature: (Fihn, 2003) (Krieger, 2003).

Treatment of Acute Bladder Infection

Management of asymptomatic bacteriuria:

For the vast majority of patients, in the absence of symptoms (dysuria, fever, pain), screening (urine culture without symptoms) is not indicated and treatment of asymptomatic bacteriuria with antibiotic therapy is expressly not recommended.

Symptomatic therapy of mild cystitis:

Mild bacterial cystitis can be managed with a wait-and-see behavior and symptomatic therapy without the use of antibiotics. Drink plenty, warm sitz baths, analgesics and anticholinergics are prescribed until the culture results are obtained. If there is insufficient improvement with symptomatic therapy, proceed with antibiotic therapy (see below). The spontaneous healing rate of acute uncomplicated cystitis after one week is 30–50%.

Antibiotic therapy of uncomplicated cystitis:

Table \ref{zystitis_resistenzen} provides an overview of the current antimicrobial resistances for common antibiotics. Antibiotics of first choice for uncomplicated cystitis are fosfomycin, nitrofurantoin, nitroxoline, pivmecillinam, trimethoprim or cotrimoxazole. They are sufficiently effective and offer a low range of complications with regard to possible side effects, emergence of resistance and impact on the microbiome.

Fosfomycin:

A single dose of 3 g Fosfomycin leads to the urinary excretion of the drug in the urine over 2–4 days with a sufficient therapeutic concentration.

Nitrofurantoin:

Nitrofurantoin is excreted via the urine, sufficient effective in uncomplicated cystitis. Dosage 100 mg 1-0-1 for 5–10 days.

Nitroxoline:

Nitroxoline is excreted via the urine, sufficient effective in uncomplicated cystitis. Dosage 250 mg 1-1-1 for 5–10 days.

Penicillins:

Pivampicillin 400 mg 1-1-1, amoxicillin with clavulanic acid 875 mg 1-0-1 for 3 days. Pivmecillinam is an antibiotic of first choice for uncomplicated cystitis. More side effects are risked with amoxicillin with clavulanic acid, it is an antibiotic of second choice.

Cephalosporins:

Cefpodoxime 100 mg 1-0-1 for 3 days. Alternatives: cefuroxim, cefdinir or cefaclor.



Trimethoprim or co-trimoxazole:

200 mg trimethoprim or 960 mg co-trimoxazole (trimethoprim 160 mg combined with sulfamethoxazole 800 mg) 1-0-1 for three days. First choice antibiotic due to its good tolerance, but there are regional high resistance levels of up to 30%.

Fluoroquinolones:

Ofloxacin 100–200 mg 1-0-1, 1-0-1 norfloxacin 400–800 mg 1-0-0, Ciprofloxacin 250–500 mg 1-0-1, levofloxacin 250–500 mg 1-0-0 for three days. Caution: due to dangerous side effects, fluoroquinolones are third choice antibiotics in uncomplicated UTI and are only approved if there is no alternative therapy

Treatment of Uncomplicated Cystitis in Men or Complicated Cystitis in Women

A urine culture should be started before initiation of treatment with co-trimoxazole, fluoroquinolones or oral cephalosporin for 7 days. After receiving the results from the urine culture, it might be necessary to adjust the choice of the antibiotic.

Treatment of Bladder Infection in Pregnancy

Possible and save antibiotics are amoxicillin 250 mg 1-1-1 p.o. or an oral cephalosporin such as Cefpodoxime 100–200 mg 1-0-1 or cefuroxim 500 mg 1-0-1 for three days. Bacteriuria without symptoms should be treated during pregnancy, since the risk for a pyelonephritis amounts to 30% [see section urinary tract infections in pregnancy].

Treatment of Bladder Infection in Children

Oral therapy for 2–4 days is usually sufficient; other studies support a treatment for 7–10 days. The following antibiotics are suitable for children: co-trimoxazole, oral cephalosporins and amoxicillin. The dosage is depending on body weight.

Treatment of Fungal Bladder Infection (Candida Cystitis)

Asymptomatic funguria should not be treated, antibody titer may help in treatment decisions. Clinical significant bladder infection are treated with fluconazole 200 mg 1-0-0 for 14 days, bladder rinsing with amphotericin B or amphotericin B i.v. in a single dose.

Prevention (Prophylaxis) of Recurrent Bladder Infection

Sex and Bladder Infections

Sexual intercourse is a strong risk factor for bladder infection (honeymoon cystitis). Following measures reduce the risk of bladder infection: micturition after sexual intercourse, high diuresis, no diaphragm or spermicide for contraception, avoidance of anal intercourse.

If above mentioned prevention measures are not effective, a single dose of antibiotics (cephalosporine, co-trimoxazole or nitrofurantoin) after sex reduces the incidence of bladder infection.

Cranberry Juice in Recurrent Cystitis

Regular consumption of cranberry juice or concentrate (twice daily) reduces the incidence of urinary tract infections (relative risk reduction of 0.6). Proposed mechanisms are the interaction of cranberry juice with the adherence abilities of the bacteria with the urothelium and bacteriostatic properties. Overall, trials are contradictory and the therapeutic effect in adults may be low (Jepson et al, 2012). Several randomized studies have shown that cranberry juice is effective in children.

Recurrent Bladder Infection in Postmenopausal Women

Estrogen deficiency in postmenopausal women is a risk factor for recurrent urinary tract infections. Estrogen replacement therapy leads to a reduction of urinary tract infections. Local estrogen replacement therapy (vaginal cream or vaginal estrogen implants) are more successful and less harmful than oral hormone replacement therapy.

Vaccination against Recurrent Bladder Infection

Oral vaccination with inactivated but immunogenic E. coli strains (e.g. Uro-Vaxom) shows a protective effect, reduction of UTI recurrence within 6–12 month by 22–65%. Dosage: one capsula p.o. over three month (Bauer et al, 2002).

Parenteral vaccination:

An intramuscular vaccination has also been shown to be effective in controlled studies with a reduction in UTI recurrences and breakthrough infections between 26–93% compared to placebo (Vahlensieck et al, 2014). Dosage of Strovac or Perison: three IM injections for basic immunization every two weeks, one refreshment injection after one year, if successful.



D-Mannose:

Nutritional supplement to reduce UTI, 2 g d-mannose daily reduces (RR 0,24) the recurrence of UTI (Kranjcec et al, 2014). Urinary excretion of d-mannose occupies the fimbriae of the coliform bacteria and reduces the adherence to the urothelium.

Low-Dose Antibiotic Prophylaxis

Low-dose antibiotic prophylaxis is considered to be an effective method for preventing recurrent urinary tract infections in patients with high levels of distress or complications. Dosage is once a day in the evening; alternatively, it can be taken once after sexual intercourse. Possible drugs and dosages: nitrofurantoin 50–100 mg, trimethoprim 50–100 mg, cotrimoxazole 240–480 mg. Long-term prophylactic use of fluoroquinolones such as ofloxacin, ciprofloxacin or norfloxacin is not permitted. Problematic are the side effects, increasing resistance and the frequently unchanged recurrence rate after the termination of the antibiotic prophylaxis \parencite{Kranz2017}.







Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z



References

Fihn 2003 FIHN, S. D.:
Clinical practice. Acute uncomplicated urinary tract infection in women.
In: N Engl J Med
349 (2003), Nr. 3, S. 259–66

Krieger 2003 KRIEGER, J. N.:
Urinary tract infections: what’s new?
In: J Urol
168 (2003), S. 2351–58.