An 18-year-old woman comes to the office due to pain on urination and "constantly feeling like I have to go to the bathroom even though I go several times every hour." The patient is sexually active with her boyfriend and, since her symptoms began 3 days ago, has felt pain during intercourse but has not had fever, chills, nausea, vomiting, or flank pain. The patient uses condoms consistently during intercourse. Her last menstrual period was 4 weeks ago. She has no chronic medical conditions or surgeries. The patient has no known drug allergies. Temperature is 37.8 C (100 F), blood pressure is 110/70 mm Hg, pulse is 82/min, and respirations are 18/min. Mild suprapubic tenderness is present on abdominal examination. Pelvic examination shows no cervical discharge or cervical motion tenderness. The remainder of the examination is normal. Urinalysis shows positive leukocyte esterase, positive nitrites, and 10 red blood cells/hpf. A decision is made to treat the patient with one week of trimethoprim-sulfamethoxazole. The patient's pregnancy test is positive. Which of the following is the most appropriate treatment for her presenting symptoms?

Question

An 18-year-old woman comes to the office due to pain on urination and "constantly feeling like I have to go to the bathroom even though I go several times every hour."  The patient is sexually active with her boyfriend and, since her symptoms began 3 days ago, has felt pain during intercourse but has not had fever, chills, nausea, vomiting, or flank pain.  The patient uses condoms consistently during intercourse.  Her last menstrual period was 4 weeks ago.  She has no chronic medical conditions or surgeries.  The patient has no known drug allergies.  Temperature is 37.8 C (100 F), blood pressure is 110/70 mm Hg, pulse is 82/min, and respirations are 18/min.  Mild suprapubic tenderness is present on abdominal examination.  Pelvic examination shows no cervical discharge or cervical motion tenderness.  The remainder of the examination is normal.  Urinalysis shows positive leukocyte esterase, positive nitrites, and 10 red blood cells/hpf.  A decision is made to treat the patient with one week of trimethoprim-sulfamethoxazole. The patient's pregnancy test is positive.  Which of the following is the most appropriate treatment for her presenting symptoms?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0a3_98ea_8f63_3d03a7e68d27_MD0005_00 Empiric antibiotic therapy is initiated in pregnant patients who have dysuria, urinary frequency, and a urinalysis consistent with acute cystitis. A urine culture is performed for all pregnant patients with acute cystitis and is repeated a week after completion of antibiotics to ensure infection resolution (eg, test of cure). Urine cultures are repeated as bacteriuria during pregnancy is associated with an increased risk for complications such as acute pyelonephritis and acute respiratory distress syndrome. Escherichia coli is the most common cause of acute cystitis in both pregnant and nonpregnant patients, but some antibiotics that are used in treatment of cystitis for nonpregnant patients are avoided during pregnancy due to their association with fetal anomalies. In pregnancy, the first-line antibiotics for acute cystitis include cephalexin, fosfomycin, and amoxicillin-clavulanate, all of which provide broad-spectrum coverage and are not teratogenic. Nitrofurantoin can also be used in the second and early third trimesters, but is avoided in the first trimester due to a risk of orofacial clefts and in the late third trimester due to an association with neonatal hemolytic anemia. (Choice B) Ceftriaxone, a third-generation cephalosporin, is given intravenously or intramuscularly and is not required in patients with uncomplicated cystitis. Oral medications are sufficient and more appropriate as they can be administered on an outpatient basis. (Choice C) Ciprofloxacin, a fluoroquinolone, is effective in treating acute cystitis in nonpregnant patients. Fluoroquinolones are avoided during pregnancy as they cross the placenta and are toxic to developing cartilage. (Choice D) Gentamicin, an aminoglycoside, is avoided during pregnancy as it crosses the placenta and is associated with irreversible congenital deafness. (Choice E) Trimethoprim-sulfamethoxazole use in the first trimester is associated with birth defects (eg, neural tube defects, cardiac defects, cleft palate) and in the late third trimester is associated with neonatal kernicterus. Educational objective: First-line antibiotic therapy for acute cystitis during pregnancy includes cephalexin, fosfomycin, and amoxicillin-clavulanate. References: Association between antibiotic use among pregnant women with urinary tract infections in the first trimester and birth defects, National Birth Defects Prevention Study 1997 to 2011. (http://www.ncbi.nlm.nih.gov/pubmed/27891788) A review of antibiotic use in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26598097) Urinary tract infections in pregnancy: old and new unresolved diagnostic and therapeutic problems. (http://www.ncbi.nlm.nih.gov/pubmed/25861291)

An 18-Year-Old Woman Comes to the Office Due to Pain