Treatment of Post-Operative Cystitis
Post-operative cystitis should be treated with nitrofurantoin 100 mg twice daily for 5-7 days as first-line therapy, or trimethoprim-sulfamethoxazole if local resistance is <20%, with fluoroquinolones reserved for cases with resistant organisms or upper urinary tract involvement. 1
What is Cystitis?
Cystitis is an inflammation of the bladder, typically caused by a bacterial infection of the lower urinary tract. In post-operative patients, it is characterized by:
- Frequency of urination
- Dysuria (painful urination)
- Suprapubic pain or discomfort
- Possible hematuria
- Cloudy or malodorous urine
Post-operative cystitis is common due to catheterization, altered immune status, and decreased mobility after surgery.
Diagnostic Approach
Urinalysis: Should be performed in all patients with suspected cystitis
- Dipstick testing for leukocyte esterase and nitrites
- Microscopic analysis for white blood cells and bacteria
Urine Culture: Recommended to confirm diagnosis and determine antimicrobial susceptibility
- A clean-catch midstream specimen is acceptable in most cases
- Catheterized specimen may be necessary in certain cases (e.g., vaginal contamination) 1
Imaging: CT urography with both nephrographic and excretory phases is the gold standard if there's concern for iatrogenic urinary tract injury 2
Treatment Algorithm
First-line Treatment:
- Nitrofurantoin 100 mg twice daily for 5-7 days (preferred in patients with normal renal function) 1
- Trimethoprim-sulfamethoxazole for 3 days (if local resistance is <20%) 1
- Fosfomycin 3g single dose (alternative option) 1
Second-line Treatment:
- Fluoroquinolones (e.g., ciprofloxacin 250 mg twice daily for 3 days) should be reserved for:
Special Considerations:
- Renal Impairment: Avoid nitrofurantoin if GFR <30 ml/min 1
- Complicated UTI: For complicated post-operative UTIs with systemic symptoms, consider broader coverage with cephalosporins or fluoroquinolones 2
- Catheterized Patients: Remove catheter as soon as possible; if continued drainage is needed, consider antimicrobial prophylaxis at catheter removal for high-risk patients 2
Treatment Efficacy and Evidence
Research shows that 3-day regimens of appropriate antibiotics are generally as effective as longer courses for uncomplicated cystitis, with fewer adverse effects 4, 5. However, in post-operative settings where patients may have risk factors for complicated UTI, a 5-7 day course is often recommended.
Studies demonstrate that:
- Fluoroquinolones like ciprofloxacin have high clinical cure rates (77-93%) but should be used judiciously due to resistance concerns 6, 7
- Beta-lactams (including amoxicillin-clavulanate) are less effective than fluoroquinolones for cystitis, with clinical cure rates of only 58-60% 7
- Despite guidelines recommending trimethoprim-sulfamethoxazole as first-line therapy, physicians often prescribe broad-spectrum antibiotics for longer than recommended durations 8
Prevention Strategies
- Early catheter removal: Remove urinary catheters as soon as clinically appropriate
- Proper catheter care: Maintain closed drainage system
- Adequate hydration: Encourage fluid intake
- Prompt voiding: Encourage complete bladder emptying
- Antibiotic prophylaxis: Consider in high-risk patients at catheter removal 2
Common Pitfalls to Avoid
- Inadequate diagnosis: Relying solely on symptoms without urinalysis or culture
- Overuse of fluoroquinolones: Reserve these for cases where first-line agents are inappropriate
- Insufficient treatment duration: Ensure complete course of antibiotics
- Failure to remove catheters promptly: Indwelling catheters increase infection risk
- Missing upper tract involvement: Assess for signs of pyelonephritis (fever, flank pain, systemic symptoms)
By following this evidence-based approach to post-operative cystitis, you can effectively treat the infection while practicing good antimicrobial stewardship.