A 19-year-old woman comes to the office due to 2 days of dysuria, urinary frequency, and urgency. The symptoms began a day after having sexual intercourse with her boyfriend. The patient has no fever, flank pain, nausea, or vomiting. She has no chronic medical conditions and no known drug allergies. Vital signs are within normal limits. Examination shows mild suprapubic tenderness. Urinalysis reveals many bacteria and white blood cells/hpf. Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 19-year-old woman comes to the office due to 2 days of dysuria, urinary frequency, and urgency.  The symptoms began a day after having sexual intercourse with her boyfriend.  The patient has no fever, flank pain, nausea, or vomiting.  She has no chronic medical conditions and no known drug allergies.  Vital signs are within normal limits.  Examination shows mild suprapubic tenderness.  Urinalysis reveals many bacteria and white blood cells/hpf.  Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

This patient's acute dysuria, urinary frequency/urgency, suprapubic tenderness, and pyuria/bacteriuria indicate acute simple cystitis. Women are at greater risk than men due to the short distance between the anus and vaginal introitus, which allows enteric bacteria to contaminate the urethra and ascend into the bladder. Recent sexual intercourse is the single greatest risk factor in otherwise healthy women. Most cases of acute simple cystitis are caused by the enteric bacteria Escherichia coli. However, Klebsiella pneumoniae, Proteus mirabilis, and Staphylococcus saprophyticus are also frequently isolated. Patients with no risk factors for resistant bacteria (eg, recent inpatient hospitalization or antibiotic use) are generally treated empirically with 3-6 days of nitrofurantoin or trimethoprim-sulfamethoxazole (TMP-SMX) due to their excellent efficacy and low risk of side effects. (Choices A and B) Azithromycin and doxycycline treat Chlamydia trachomatous infections of the urogenital tract. Most cases of chlamydia are asymptomatic, but some patients have dysuria and urinary frequency. Although urinalysis will reveal pyuria, no bacteria would be seen on urinary Gram stain because C trachomatous has no cell wall. Neither azithromycin nor doxycycline adequately treats enteric, gram-negative pathogens; therefore, neither is typically used for acute simple cystitis. (Choice C) Fluconazole is often used to treat vaginal candidiasis, which can cause dysuria and is often linked to vaginal intercourse. However, most patients also have vaginal itching and soreness. The presence of urinary frequency, urgency, and pyuria/bacteriuria makes bacterial cystitis more likely. (Choice D) Metronidazole can treat Trichomonas vaginalis, a flagellated protozoan that is transmitted during sexual intercourse. Women infected with trichomonas often have dysuria and frequency, but most also have a purulent, malodourous vaginal discharge. The presence of pyuria/bacteriuria on urinalysis makes acute bacterial cystitis more likely. Educational objective: Acute simple cystitis often occurs in young, otherwise healthy women, particularly following sexual intercourse. Common manifestations include dysuria, urinary frequency/urgency, and urinalysis evidence of pyuria/bacteriuria. Empiric treatment with nitrofurantoin or trimethoprim-sulfamethoxazole is typically curative.

A 19-Year-Old Woman Comes to the Office Due to 2