What is the pathophysiology and treatment of cystitis?

From the Guidelines

Cystitis is an inflammation of the bladder typically caused by bacterial infection, most commonly Escherichia coli, and the most effective treatment involves a short course of antibiotics, with first-line options including nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin, as recommended by the American College of Physicians in 2021 1. The pathophysiology of cystitis involves bacterial ascension through the urethra to the bladder, where pathogens adhere to the bladder epithelium, multiply, and trigger an inflammatory response, leading to characteristic symptoms of urinary frequency, urgency, dysuria, and occasionally hematuria.

Key Points to Consider

• The most recent guidelines from the American College of Physicians in 2021 1 recommend short-course antibiotics for uncomplicated cystitis, with options including nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole for 3 days, or fosfomycin as a single dose.
• The choice of antibiotic should be based on the patient's medical history, antibiotic susceptibility, and local resistance patterns, as noted in the 2011 guidelines from the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases 1.
• Fluoroquinolones, such as ciprofloxacin, are highly efficacious but have a high propensity for adverse effects and should be reserved for cases where first-line agents cannot be used due to resistance concerns 1.
• Symptomatic relief can be achieved with phenazopyridine for urinary pain and increased fluid intake.
• Prevention strategies include adequate hydration, urinating after sexual intercourse, and proper wiping technique from front to back in women.

Treatment Options

• Nitrofurantoin: 100mg twice daily for 5 days
• Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days
• Fosfomycin: 3g single dose
• Fluoroquinolones (e.g. ciprofloxacin): reserved for cases where first-line agents cannot be used due to resistance concerns The American College of Physicians recommends that clinicians prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole for 3 days, or fosfomycin as a single dose for women with uncomplicated bacterial cystitis 1.

From the FDA Drug Label

Adult Patients: Urinary Tract Infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, Providencia rettgeri, Morganella morganii, Citrobacter diversus, Citrobacter freundii, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus epidermidis, Staphylococcus saprophyticus, or Enterococcus faecalis Acute Uncomplicated Cystitis in females caused by Escherichia coli or Staphylococcus saprophyticus.

The pathophysiology of cystitis is not directly described in the provided drug label. However, it can be inferred that cystitis is caused by bacterial infections, specifically by Escherichia coli or Staphylococcus saprophyticus in the case of acute uncomplicated cystitis in females. The treatment of cystitis, specifically acute uncomplicated cystitis, is indicated to be treated with ciprofloxacin 2. Key points about the treatment of cystitis include:

• The drug label indicates that ciprofloxacin is effective against Escherichia coli and Staphylococcus saprophyticus, which are common causes of cystitis.
• Ciprofloxacin is used to treat urinary tract infections, including cystitis.

From the Research

Pathophysiology of Cystitis

• Cystitis is a type of urinary tract infection (UTI) that occurs when bacteria enter the bladder and cause inflammation 3.
• The pathophysiology of cystitis involves the adherence of bacteria to the bladder mucosa, leading to an inflammatory response and the production of symptoms such as dysuria, frequency, and urgency 3.

Treatment of Cystitis

• The treatment of cystitis typically involves the use of antibiotics, with the choice of antibiotic depending on the severity of the infection and the presence of any underlying medical conditions 4, 3.
• First-line treatment options for acute uncomplicated cystitis include nitrofurantoin, fosfomycin, and pivmecillinam, while second-line options include oral cephalosporins, fluoroquinolones, and beta-lactams 3.
• The effectiveness of different antibiotics for the treatment of cystitis can vary depending on the patient's renal function, with nitrofurantoin being a good option for patients with normal renal function and fosfomycin being a good option for patients with impaired renal function 5.
• It is essential to use antibiotics wisely and follow guidelines to avoid the development of antimicrobial resistance 3, 6.

Antibiotic Resistance and Treatment Failure

• Antibiotic resistance is a growing concern in the treatment of cystitis, with high rates of resistance to trimethoprim-sulfamethoxazole and fluoroquinolones reported in some areas 3, 6.
• Treatment failure can occur due to antibiotic resistance, and it is essential to monitor patients for signs of treatment failure and adjust the antibiotic regimen as needed 7, 5.
• The use of nitrofurantoin, fosfomycin, and other antibiotics can help to reduce the risk of treatment failure and the development of antimicrobial resistance 4, 3, 7, 5.