Question 1 of 10

    Acute Cystitis

    Pyuria[1]

    Acute cystitis is a condition involving an infectious inflammation of the lower urinary tract, namely the urinary bladder.

    The disorder originates from the following process: infectious.

    Presentation

    Acute cystitis with no subsequent complications causes typical symptomatology that may even be diagnosed without a visit to the doctor [9]. Symptoms include:

    The presence of complications is diagnosed if other symptoms are present, such as fever and nausea, chills, abdominal or back pain and vaginal discharge.

    urogenital
    Hematuria
    • hematuria N3031Trigonitis with hematuria N3080Other cystitis without hematuria N3081Other cystitis with hematuria N3090Cystitis, unspecified without hematuria N3091Cystitis, unspecified with hematuria N340Urethral abscess N342Other urethritis N343Urethral[cms.gov]
    • Convert to ICD-10-CM : 595.0 converts approximately to: 2015/16 ICD-10-CM N30.00 Acute cystitis without hematuria Or: 2015/16 ICD-10-CM N30.01 Acute cystitis with hematuria Approximate Synonyms Acute cystitis (bladder infection) in pregnancy, before birth[icd9data.com]
    • ICD-10-CM Codes › N00-N99 Diseases of the genitourinary system › N30-N39 Other diseases of the urinary system › N30- Cystitis › Acute cystitis without hematuria 2016 2017 2018 Billable/Specific Code N30.00 is a billable/specific ICD-10-CM code that can[icd10data.com]
    • Signs of a bladder infection are pyuria, bacteriuria, hematuria or a positive nitrite test.[urology-textbook.com]
    • With cystitis, you may have blood cells in your urine that can be seen only with a microscope (microscopic hematuria) and that usually resolves with treatment.[mayoclinic.org]
    Dysuria
    • Women who have dysuria and pyuria but without significant bacteriuria have the urethral syndrome or dysuria-pyuria syndrome.[merckmanuals.com]
    • Signs and Symptoms Irritable bladder symptoms: dysuria, urinary frequency , urinary urgency, sometimes urge incontinence.[urology-textbook.com]
    • Definition / general A clinical diagnosis, usually with a triad of frequency, lower abdominal pain and dysuria (pain or burning during urination) There is usually no surgical specimen for acute cystitis, although it may be a finding in a specimen obtained[pathologyoutlines.com]
    • No women will eschew an ED visit after the first episodes of bright red urine or the stinging and burning of dysuria.[journals.lww.com]
    Urinary Urgency
    • Signs and Symptoms Irritable bladder symptoms: dysuria, urinary frequency , urinary urgency, sometimes urge incontinence.[urology-textbook.com]
    • Classic symptoms include dysuria, frequent voiding of small volumes, and urinary urgency.[cdc.gov]
    • Clinical Presentation of Acute Cystitis Patients with acute cystitis complain of dysuria , urinary urgency and increased urinary frequency .[lecturio.com]
    • The disorder is characterized by urinary urgency, frequency, dysuria, suprapubic discomfort and, in some patients, a low-grade fever.[clinicaladvisor.com]
    Suprapubic Pain
    • Signs of cystitis (Contrast with Pyelonephritis) Afebrile Suprapubic Pain No Costovertebral angle (CVA) tenderness VIII.[fpnotebook.com]
    • Suprapubic pain Cloudy urine or hematuria Complication: Ascension of the pathogens with pyelonephritis , risk factors are vesicoureteral reflux and UTI in pregnancy .[urology-textbook.com]
    • Symptoms of urgency, frequency, urinary burning, and suprapubic pain drive most women to the ED in search of a cure.[journals.lww.com]
    • The most common form of UTI is cystitis (bladder infection) characterized by irritative symptoms such as urinary urgency, frequency, dysuria, hematuria, foul- smelling urine, and suprapubic pain.[auanet.org]
    • Acute cystitis is more likely if the woman complains of urgency and suprapubic pain; has suprapubic tenderness; is a diaphragm-spermicide user; has symptoms that mimic those of previously confirmed cystitis; or has recently undergone urethral instrumentation[antimicrobe.org]
    Cloudy Urine
    • Gross pathology includes cloudy urine, hyperaemic and oedematous mucosa, haemorrhages and blood clots and catarrhal exudate on the mucosal surface in severe inflammation Histopathology will show epithelial degeneration and necrosis, leukocyte infiltration[en.wikivet.net]
    • Acute infections of the bladder occur when bacteria enter the urethra or bladder and grow out of control, causing symptoms including a burning sensation during urination, abdominal pain and bloody or cloudy urine.[livestrong.com]
    • These symptoms include a frequent urge to urinate even after you have emptied your bladder, a burning sensation when urinating, strong-smelling urine, cloudy urine, sensation of pressure, bladder fullness, or pain of the lower back or abdomen, a low fever[belmarrahealth.com]
    • Suprapubic pain Cloudy urine or hematuria Complication: Ascension of the pathogens with pyelonephritis , risk factors are vesicoureteral reflux and UTI in pregnancy .[urology-textbook.com]
    • urine; blood in the urine .[webmd.com]
    Urinary Retention
    • Retention - NIH (National Institute of Diabetes and Digestive and Kidney Diseases) [ Read More ] Urine and Urination Your kidneys make urine by filtering wastes and extra water from your blood.[icdlist.com]
    • retention, which needs further workup Differential Diagnosis: Acute Cystitis Men Urethritis and prostatitis, again usually distinguished by physical exam Cystitis in men is rare and usually means pathologic process such as stone, prostatitis or urinary[quizlet.com]
    • retention) Procedures that involve the urinary tract Staying still (immobile) for a long period of time (for example, when you are recovering from a hip fracture ) Most cases are caused by Escherichia coli ( E coli ) .[medlineplus.gov]
    • retention) Procedures that involve the urinary tract Staying still (immobile) for a long period of time (for example, when you are recovering from a hip fracture) Most cases are caused by Escherichia coli (E. coli) , a type of bacteria found in the intestines[scripps.org]
    • In men with urinary retention, a urethral or suprapubic catheter is necessary.[clevelandclinicmeded.com]
    Urinary Incontinence
    • Sepia: Use this medicine for Cystitis when it is associated with sagging or prolapse of the bladder causing symptoms of urinary incontinence and a bearing down sensation.[thehomeopathiccoach.com]
    • Some common ones are Cystitis - inflammation of the bladder, often from an infection Urinary incontinence - loss of bladder control Overactive bladder - a condition in which the bladder squeezes urine out at the wrong time Interstitial cystitis - a chronic[icdlist.com]
    • In older children, new onset urinary incontinence (loss of bladder control) may occur.[en.wikipedia.org]
    • incontinence fecal incontinence residual urine with ischemia of bladder wall Bacterial Uropathogenic Factors A limited number of E. coli serotypes are responsible for the majority of UTIs.[auanet.org]
    Foul Smelling Urine
    • […] but in most cases one or more of the following will be present: pain, burning or discomfort during urination; frequent need to urinate, though only small amounts of urine may come out; nighttime urination; pain in the lower back or abdomen ; strong or foul-smelling[webmd.com]
    • The symptoms of a bladder infection include: Cloudy or bloody urine Strong or foul smelling urine Low fever (not everyone will have a fever) Pain or burning with urination Pressure or cramping in the lower middle abdomen or back Strong need to urinate[medlineplus.gov]
    • Symptoms The symptoms of a bladder infection include: Cloudy or bloody urine Strong or foul smelling urine Low fever (not everyone will have a fever) Pain or burning with urination Pressure or cramping in the lower middle abdomen or back Strong need to[scripps.org]
    • The most common form of UTI is cystitis (bladder infection) characterized by irritative symptoms such as urinary urgency, frequency, dysuria, hematuria, foul- smelling urine, and suprapubic pain.[auanet.org]
    Pelvic Pain
    • Management of patients with interstitial cystitis or chronic pelvic pain of bladder origin: a consensus report.[lifescript.com]
    • Chronic prostatitis in the forms of chronic prostatitis/chronic pelvic pain syndrome and chronic bacterial prostatitis (not acute bacterial prostatitis or asymptomatic inflammatory prostatitis) may cause recurrent urinary tract infections in males.[en.wikipedia.org]
    • If organisms are not present, the patient may have chronic pelvic pain syndrome.[atsu.edu]
    Nocturia
    • […] similar symptomatology Associated diseases Severe allergies IBS and IBD Theories Increased epithelial permeability Sensory nervous system problems Autoimmunity Signs and Symptoms Pain with bladder filling Relieved with urination Urgency, frequency, and nocturia[quizlet.com]
    • Nocturia, with suprapubic pain and often low back pain, is common.[merckmanuals.com]
  • more...
  • gastrointestinal
    Abdominal Pain
    • They are: fever , flank or high abdominal pain, tenderness in the CVA area and palpation over the kidney.[childrensmercy.org]
    • Acute infections of the bladder occur when bacteria enter the urethra or bladder and grow out of control, causing symptoms including a burning sensation during urination, abdominal pain and bloody or cloudy urine.[livestrong.com]
    • Definition / general A clinical diagnosis, usually with a triad of frequency, lower abdominal pain and dysuria (pain or burning during urination) There is usually no surgical specimen for acute cystitis, although it may be a finding in a specimen obtained[pathologyoutlines.com]
    • The most common symptoms of acute cystitis include: • Burning or pain when urinating • Cloudy, bloody or odd-smelling urine • Frequent and sometimes intense urges to urinate • Lower back or abdominal pain • An inability to urinate despite the urge to[cblpath.com]
    • Lower abdominal pain is also commonly found in patients with cystitis.[lecturio.com]
    Suprapubic Pain
    • Signs of cystitis (Contrast with Pyelonephritis) Afebrile Suprapubic Pain No Costovertebral angle (CVA) tenderness VIII.[fpnotebook.com]
    • Suprapubic pain Cloudy urine or hematuria Complication: Ascension of the pathogens with pyelonephritis , risk factors are vesicoureteral reflux and UTI in pregnancy .[urology-textbook.com]
    • Symptoms of urgency, frequency, urinary burning, and suprapubic pain drive most women to the ED in search of a cure.[journals.lww.com]
    • The most common form of UTI is cystitis (bladder infection) characterized by irritative symptoms such as urinary urgency, frequency, dysuria, hematuria, foul- smelling urine, and suprapubic pain.[auanet.org]
    • Acute cystitis is more likely if the woman complains of urgency and suprapubic pain; has suprapubic tenderness; is a diaphragm-spermicide user; has symptoms that mimic those of previously confirmed cystitis; or has recently undergone urethral instrumentation[antimicrobe.org]
    Acute Abdomen
    • Patients with abdominal pain or tenderness are evaluated for other causes of an acute abdomen .[merckmanuals.com]
  • more...
  • Entire body system
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  • Workup

    The diagnosis of acute cystitis is accomplished primarily via the patient's symptom reporting and a dipstick testing. Patients are expected to report dysuria, urgency and frequent urination, whereas the physical examination reveals no abnormal findings, apart from 15% of the cases, which present with tenderness in the suprapubic area [10]. A dipstick testing is the first choice to confirm a suspected uncomplicated cystitis and should reveal leukocyte esterase and nitrites. The usual procedure involves urine collected after washing of the urogenital area and specifically urine from the middle of the stream; however, studies have shown that even if the procedure is not followed, i.e. in emergency cases, there is no contamination that would render the results falsely positive [11].

    Further assessment with a urine culture and imaging is not necessary and is reserved from patients who suffer from recurrent cystitis, those who do not respond to treatment and for patients with a suspected complicated acute cystitis.  

    Laboratory

    Urine
    Pyuria
    • Pyuria may or may not be present.[merckmanuals.com]
    • Pyuria presence is a very good sign of acute cystitis, but the specificity is usually low.[lecturio.com]
    • (with counts of 10 leukocytes per mm 3 suggesting infection); the leukocyte esterase dipstick test (a rapid-screening test for pyuria since leukocyte esterase is found in neutrophils and its presence indicates white blood cells); and the nitrite test[uspharmacist.com]
    • Also, pyuria alone correlates poorly with dx of UTI's In the past, colony count of 10 5/mL was criteria for UTI But, at least 50% of women with symptomatic UTI's have lower counts.[quizlet.com]
    • Signs of a bladder infection are pyuria, bacteriuria, hematuria or a positive nitrite test.[urology-textbook.com]
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  • Test Results

    Cystoscopy
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  • Treatment

    The treatment of acute, uncomplicated cystitis in women of any age is usually empirical. Possible antibiotic choices include [12]:

    • Nitrofurantoin monohydrate. It should not be administered if the patient is suspected to suffer from complications such as pyelonephritis or if the patient exhibits creatinine clearance less than 60 mL per min.
    • TMP-SMX (Trimethoprim-sulfamethoxazole). If the patient has already been treated with the agent, its use is not recommended, unless the bacterial strain responsible for the cystitis is known to be sensitive to TMP-SMX. Trimethoprim may be used as an equivalent drug [13].
    • Fosfomycin. Should not be administered if the patient is suspected to suffer from pyelonephritis.
    • Fluoroquinolones. They are used when the aforementioned antibiotics are contraindicated but should be reserved for severer infections.
    • Pivmecillinam. An antibiotic of the penicillin class, it is less effective than fluoroquinolones or TMP-SMX but it has low rates of resistance [14].

    There are various criteria that a physician should bear in mind before making the choice of an appropriate antibiotic treatment. Antimicrobials are chosen based on studies concerning local resistance prevalence, cost, previous treatments, hypersensitivity and the ability to adhere to a treatment plan. Fosfomycin, nitrofurantoin and pivmecillinam are unable to reach a therapeutic concentration in the kidneys and are therefore rejected when a patient is suspected to be suffering from pyelonephritis.

    Prognosis

    Acute cystitis is a frequent urinary tract infection with excellent prognosis after appropriate antibiotic treatment is administered [8].

    Complications

    Acute Pyelonephritis
    • Antibiotics for acute pyelonephritis in Children.[childrensmercy.org]
    • Clinical Management of Acute Pyelonephritis Usta TA. et al.[antimicrobe.org]
    • Acute pyelonephritis Antibiotics are required.[merckmanuals.com]
    • Acute Pyelonephritis with Intrarenal, Perirenal or Pararenal Abscess Treatment for complicated UTI and add appropriate drainage.[auanet.org]
    • C 6 A urine culture is recommended for women with suspected acute pyelonephritis, women with symptoms that do not resolve or that recur within two to four weeks after the completion of treatment, and women who present with atypical symptoms.[aafp.org]
    Perinephric Abscess
    • […] tubulo-interstitial nephritis N119Chronic tubulo-interstitial nephritis, unspecified N12Tubulo-interstitial nephritis, not specified as acute or chronic N135Crossing vessel and stricture of ureter without hydronephrosis N136Pyonephrosis N151Renal and perinephric[cms.gov]
    • Occasionally, a renal cortical abscess or perinephric abscess requires surgical drainage.[merckmanuals.com]
    • Perinephric abscesses are associated most commonly with E coli, Proteus species, and S aureus but also may be secondary to Enterobacter, Citrobacter, Serratia, Pseudomonas, and Klebsiella species.[emedicine.medscape.com]
    Chronic Pyelonephritis
    • pyelonephritis N118Other chronic tubulo-interstitial nephritis N119Chronic tubulo-interstitial nephritis, unspecified N12Tubulo-interstitial nephritis, not specified as acute or chronic N135Crossing vessel and stricture of ureter without hydronephrosis[cms.gov]
    • […] infections where some of the pathogens are resistant, Renal insufficiency, & Rapid emergence of resistant organism that was initially sensitive Urinary tract initially sterilized during therapy, but persistent source of infection remains: Infected stones Chronic[quizlet.com]

    Etiology

    Acute cystitis is an infection of the lower urinary tract. The most common pathogens are:

    • E. coli. It is responsible for up to 90% of bladder infections.
    • Klebsiella spp.
    • Proteus spp.
    • Staphylococcus saprophyticus
    • Enterococcus faecalis
    • Candida albicans
    • Any gram negative bacterium that exhibits resistance to a multitude of drugs, which is found in the hospital setting. Each facility has its own specific pathogens that display an increased antimicrobial resistance [3]; the exact prevalence is important for the planning of the treatment.

    In addition to the pathogens responsible for most cases of acute cystitis, various other circumstances increase the possibility of a patient sustaining such an infection. Catheterization is a standard risk factor for the development of cystitis, as they constitute fertile ground for the adhesion of pathogens [4]. A catheter can also be the means through which bacteria originally infect the cyst. Other risk factors include spermicide and diaphragm used as a contraceptive measure, as well as sexual activity. Another factor that has been proposed as increasing the possibility of a urinary tract infection is a gynecological pelvic exam, which can contribute to a bladder infection even in seven weeks after the test [5]. Pregnancy, senior age or congenital structural defects of the urinary tract also render an individual more susceptible to infection.

    Renal transplantation is also a risk factor for the development of a UTI. Subsequent immunosuppression and the vesicoureteral reflex are the pathophysiological mechanisms leading to such a manifestation. Patients who have undergone a renal transplantation run a higher risk of infection with Corynebacterium urealyticum for the 2-month period following the surgery.

    With regard to acute cystitis caused by candidiasis, risk factors include urinary catheters, antibiotics and diabetes mellitus.

    Causes

    Epidemiology

    Acute cystitis frequently affects female patients and particularly younger women who are sexually active. The incidence has been calculated as amounting to approximately 1 infection per year amongst those women [6]. Spermicide use for contraceptive purposes, a medical history of prior UTIs and recent sexual activity all contribute to the infection. Apart from younger women, however, women who have already experienced menopause are also at a risk for cystitis, although the incidence is much lower in this particular subgroup, when compared to younger female patients.

    Sex distribution
    Age distribution

    Pathophysiology

    Acute cystitis involves the presence of bacterial load within the bladder, which causes infection accompanied by typical symptomatology. The urinary tract contains no bacteria in healthy individuals. In some cases, various pathogens may be present in the region of the cyst; they invade the mucosa of the cyst and establish a bladder infection.

    There are 3 pathophysiological mechanisms which lead to a urinary tract infection and, more specifically, an acute cystitis. Pathogens may enter the cyst from the urethra, following an ascending route or they may be translocated into the bladder from the perineal region. These two mechanisms are the most prominent; a third route of bladder microbial infestation is the hematogenous dissemination type. This mechanism is less often observed and involves pathogens entering the cyst via the blood.

    Women tend to be affected by acute cystitis more often than men do. This is attributed to the female urethra, which is shorter in length, allowing for the entrance of microorganisms. Once the pathogens have entered the cyst and attached themselves to the epithelium, they reproduce rapidly; the highest bacterial load has been observed 2 days before the onset of symptomatology [7].

    A plethora of pathogens can be potential culprits for a urinary tract infection, but the ones most commonly isolated are gram negative bacteria of the fecal flora. Apart from their being naturally found in the perineal area, which is in close proximity to the urethra, those bacterial strains have specific properties that enable them to establish acute cystitis. Particular structures, such as fimbriae and proteins of the external membrane in E.coli strains, enable the bacteria to attach themselves to glycolipids of the cyst's epithelium, thus causing an acute infection. Other characteristics that promote bacterial adhesion in the urinary tract epithelium include hemolysins, cytotoxic necrotizing factor (CNF) protein and polysaccharides ; pathogens containing these products are more likely to initiate a urinary tract infection than others. Finally there are also other bacterial traits that render some strains more capable of establishing acute cystitis: Proteus mirabilis possesses genes that are activated whenever the microorganism is attached to a solid surface, such as a catheter. This activation leads to mass mobilization of the bacteria which travel towards the cyst, following the catheter's route.

    Acute cystitis is not only established when a bacterial strain capable of infection is present in the cyst. The defensive mechanisms of the urinary tract itself play an equally important role. Frequent urination is a simple and effective measure which helps to "flush" the cyst of any pathogens that may be present within, thus diminishing the cyst's bacterial load. Vaginal lactobacilli also prevent from bacterial colonization in women who have not yet entered the menopausal period; the disruption of the vaginal flora, induced by almost all antibiotics, may frequently lead to acute cystitis. Another factor that protects the urinary tract from infection is IgA immunoglobulin: ABH blood antigen non-secretors are more susceptible to cystitis compared to secretors. Finally, urine acidity, osmolality and urea additionally help to eradicate bacteria that are found in the bladder.

    Given the aforementioned mechanisms, risk factors for the development of acute cystitis are:

    • Failure to urinate frequently
    • Catheter use
    • Sexual intercourse
    • Obstruction of the urinary tract
    • Vesicoureteral reflux

    The basic pathophysiology of acute cystitis can be summarized to an increased bacterial virulence and decreased defensive mechanisms of any individual.

    Prevention

    There are many suggestions that can considerably reduce a woman's chance of developing acute cystitis and include:

    • Urination before and after sexual intercourse
    • Wiping from the front to the back to avoid dispersion of fecal bacteria
    • Frequent urination
    • Avoidance of spermicide
    • Non-barrier contraception

    In general, a patient receives antibiotic treatment when they report cystitis-related symptoms. Treatment of asymptomatic bacteriuria is recommended only in pregnant individuals, in order to prevent complications such as pyelonephritis, which cause a preterm labor or even pregnancy termination.

    Prophylactic antibiotics, taken every day or after sexual intercourse, are also a recommendation for women who experience recurrent urinary tract infections. Proposed antimicrobials include TMP-SMX, nitrofurantoin and methenamine; the latter is reserved for short-term prophylactic treatment [15]. The consumption of cranberry juice can also be encouraged although there is no scientific data to support its beneficial effect.

    Summary

    Infections can occur to any segment of the urinary tract. Acute cystitis is the most common type of urinary tract infection (UTI) [1] and affects the lower part of the tract, as opposed to the kidneys, which constitute the upper urinary tract.

    Women are particularly susceptible to UTIs, due to anatomical differences in contradistinction to men; almost 1 out of 5 women will be affected by an infection of the urinary bladder at least once in their life.

    Infections are caused by various bacteria and primarily by the gram negative Escherichia coli. Klebsiella pneumonia, Proteus mirabilis and Enterococcus faecalis are the next most common pathogens leading to an UTI. Acute cystitis with no complications is diagnosed with a careful clinical examination and urinalysis, which should display a significant pathogen load in the urine alongside typical symptomatology reported by the patient [2]. Treatment is carried out with antibiotics. First-choice antibiotics against acute cystitis are drugs that target gram negative pathogens, since most cases of cystitis are a result of infection with bacterial strains of microorganisms normally found in the human digestive tract and, subsequently, in excrement.

    Patient Information

    Acute cystitis is an infection of the bladder caused by various bacteria. Since the urinary tract normally contains no flora, namely bacteria that are located there and serve a purpose, when microorganisms enter the region of the bladder they are expected to cause a reaction. Bladder infections are most commonly caused by bacteria of the fecal flora. Those ascend to the bladder through the urethra, either during sexual intercourse or while wiping oneself in the toilet. Other possible causes for a bladder infection are a weakened immune system, keeping urine in the bladder for too long before urinating, the use of spermicide and a wrong-placed diaphragm. Diabetes is also a risk factor for the development of acute cystitis, as are poor hygiene habits, catheters, pregnancy and immobility. Women are

    A bladder infection is simple to diagnose, as the patients present with a typical triad of symptoms: pain during urination, urgency to urinate and the need to urinate abnormally frequently. Blood may be seen in the urine, alongside a different smell. A dipstick testing is quick, noninvasive and fast and is safe to diagnose acute cystitis in an individual. Patients who do not respond to treatment or suffer from recurring infections may need to undergo further assessment in order to establish the diagnosis.

    After acute cystitis is diagnosed, it is treated with antibiotics that a physician will prescribe without a culture. Choices include TMP-SMX, nitrofurantoin, beta lactames and other agents. A doctor will ask you for any prior hypersensitivity occurrences, whether you have recently been treated with any of the proposed antibiotics and will proceed to the administration of the medication. The prognosis is excellent. 

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    References

    1. Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008 Mar; 22(1):73-87, vi.
    2. Little P, Turner S, Rumsby K, et al. Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study. Health Technol Assess. 2009 Mar; 13(19):iii-iv, ix-xi, 1-73.
    3. Kanj SS, Kanafani ZA. Current concepts in antimicrobial therapy against resistant gram-negative organisms: extended-spectrum beta-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa. Mayo Clin Proc. 2011 Mar; 86(3):250-9.
    4. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010 Mar 1; 50(5):625-63.
    5. Tiemstra JD, Chico PD, Pela E. Genitourinary infections after a routine pelvic exam. J Am Board Fam Med. 2011 May-Jun; 24(3):296-303.
      Hooton TM, Scholes D, Hughes JP, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med. 1996; 335:468.
    6. Czaja CA, Stamm WE, Stapleton AE, et al. Prospective cohort study of microbial and inflammatory events immediately preceding Escherichia coli recurrent urinary tract infection in women. J Infect Dis. 2009 Aug 15; 200(4):528-36.
    7. Foxman B, Barlow R, D'Arcy H, et al. Urinary tract infection: self-reported incidence and associated costs. Ann Epidemiol. 2000; 10:509-515.
    8. Campbell J, Felver M, Kamarei S. 'Telephone treatment' of uncomplicated acute cystitis. Cleve Clin J Med. 1999; 66:495-501.
    9. Stamm WE. Urinary tract infections. In: Root RK, Waldvogel F, Corey L, Stamm WE. Clinical Infectious Diseases: A Practical Approach. New York, NY: Oxford University Press. 1999; 649–656.
    10. Bradbury SM. Collection of urine specimens in general practice: to clean or not to clean? J R Coll Gen Pract. 1988; 38(313):363–365.
    11. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011; 52:e103.
    12. Warren JW, Abrutyn E, Hebel JR, et al. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA). Clin Infect Dis. 1999; 29:745.
    13. Graninger W. Pivmecillinam--therapy of choice for lower urinary tract infection. Int J Antimicrob Agents. 2003; 22 Suppl 2:73.
    14. Lee BS, Bhuta T, Simpson JM, et al. Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev. 2012; (10):CD003265.
    15. Lee BS, Bhuta T, Simpson JM, et al. Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev. 2012; (10):CD003265.

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