What are the findings in Urine Routine Examination (R/M) in a patient with Cystitis?

From the Guidelines

Urine routine and microscopy (R/M) is essential in the diagnosis of cystitis, as it provides rapid results to guide initial management while cultures are pending. The presence of pyuria (>5-10 white blood cells per high power field), hematuria (presence of red blood cells), and bacteriuria in the urine R/M supports a diagnosis of urinary tract infection 1. In uncomplicated cystitis, empiric antibiotic therapy can be started based on these findings without waiting for culture results. Common antibiotic regimens include nitrofurantoin 100mg twice daily for 5 days, trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days, or fosfomycin 3g single dose 1.

Some key points to consider in the management of cystitis include:

• The presence of nitrites in the urine R/M indicates gram-negative bacteria, while leukocyte esterase suggests white blood cells in the urine, both supporting a diagnosis of urinary tract infection 1.
• For recurrent or complicated cystitis, urine culture with sensitivity testing is essential to guide targeted antibiotic therapy 1.
• Patients should also be advised to increase fluid intake, urinate frequently, and complete the full course of antibiotics even if symptoms resolve earlier 1.
• The urine R/M is valuable because it helps to distinguish bacterial cystitis from other conditions like interstitial cystitis or urethritis that may present with similar symptoms but require different management approaches 1.

The most recent and highest quality study recommends the use of short-course antibiotics in the treatment of uncomplicated cystitis, with options including nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin 1. This approach is supported by the American College of Physicians and is based on the best available evidence 1.

From the Research

Urine R/M in Cystitis

• The diagnosis of uncomplicated cystitis is usually easily made based on the clinical presentation, and treatment is usually straightforward with one of several effective short-course antimicrobial regimens 2.
• However, antimicrobial resistance continues to increase and can complicate treatment choices in certain areas 3, 4, 2.
• Nitrofurantoin is a recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females, with a 5-day course being equivalent clinically and microbiologically to a 3-day course of trimethoprim-sulfamethoxazole 3, 5.
• Nitrofurantoin retains antimicrobial activity against multidrug-resistant urinary Escherichia coli from US outpatients, making it a reliable first-line agent for the empirical treatment of acute uncomplicated cystitis 6.
• Other treatment options for UTIs include fosfomycin, pivmecillinam, fluoroquinolones, and β-lactams, such as amoxicillin-clavulanate, with the choice of treatment depending on the severity of the infection and the susceptibility of the uropathogen 3, 4.

Treatment Options

• First-line options:
  • Nitrofurantoin (5-day course) 3, 5
  • Fosfomycin (3-g single dose) 3
  • Pivmecillinam (5-day course) 3
• Second-line options:
  • Oral cephalosporins (e.g. cephalexin, cefixime) 3
  • Fluoroquinolones 3, 4
  • β-lactams (e.g. amoxicillin-clavulanate) 3, 4
• Treatment options for UTIs due to ESBLs-E coli and ESBLs-Klebsiella pneumoniae include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 3.

Resistance Patterns

• High rates of resistance to trimethoprim-sulfamethoxazole and ciprofloxacin have been reported, making them less effective as empiric treatments for UTIs 3, 4, 6.
• Nitrofurantoin has been shown to retain antimicrobial activity against multidrug-resistant urinary Escherichia coli, making it a reliable first-line agent for the empirical treatment of acute uncomplicated cystitis 6.