A 64-year-old man with a history of benign prostate hyperplasia comes to the office with 2 days of dysuria, increased urinary frequency, and suprapubic discomfort. The patient had similar symptoms 3 months ago and was treated with antibiotics. This resolved his urinary symptoms, but he developed Clostridium difficile colitis, which necessitated oral vancomycin therapy. The patient currently has no gastrointestinal symptoms. His other medical problems include hypertension and hyperlipidemia.
Temperature is 37.6 C (99.8 F), blood pressure is 124/72 mm Hg, and pulse is 86/min. The abdomen is soft, nondistended, and nontender with normal bowel sounds. There is no costovertebral angle tenderness. The prostate is moderately enlarged, smooth, and nontender.
Urine dipstick is positive for leukocyte esterase and nitrite. His previous urine culture had grown Escherichia coli, which was sensitive to all tested antibiotics.
Which of the following is the most appropriate initial antimicrobial therapy for this patient given his history of C difficile colitis?

Question

A 64-year-old man with a history of benign prostate hyperplasia comes to the office with 2 days of dysuria, increased urinary frequency, and suprapubic discomfort.  The patient had similar symptoms 3 months ago and was treated with antibiotics.  This resolved his urinary symptoms, but he developed Clostridium difficile colitis, which necessitated oral vancomycin therapy.  The patient currently has no gastrointestinal symptoms.  His other medical problems include hypertension and hyperlipidemia.
Temperature is 37.6 C (99.8 F), blood pressure is 124/72 mm Hg, and pulse is 86/min.  The abdomen is soft, nondistended, and nontender with normal bowel sounds.  There is no costovertebral angle tenderness.  The prostate is moderately enlarged, smooth, and nontender.
Urine dipstick is positive for leukocyte esterase and nitrite.  His previous urine culture had grown Escherichia coli, which was sensitive to all tested antibiotics.
Which of the following is the most appropriate initial antimicrobial therapy for this patient given his history of C difficile colitis?

Quizplus · Accepted Answer

11ec193a_964b_a4cd_853d_0fecf8f678de_MD0002_00 This patient with a history of benign prostatic hypertrophy likely has complicated cystitis; in the outpatient setting, complicated cystitis is usually managed with an oral fluoroquinolone. However, fluoroquinolones are associated with a high risk of Clostridium difficile-associated diarrhea (CDAD) and should generally be avoided in those with a history of CDAD when an alternate, lower-risk antibiotic is available (Choice C). The patient's recent episode of cystitis was due to pansensitive Escherichia coli; therefore, treatment with trimethoprim-sulfamethoxazole would likely provide adequate coverage while also conferring a low risk of CDAD. (Choice A) This patient has normal vital signs and no vomiting; he can be treated in the outpatient setting with oral antibiotics. In addition, broad-spectrum cephalosporins such as ceftriaxone are associated with a high risk of C difficile relapse. (Choice B) Broad-spectrum penicillins such as amoxicillin-clavulanic acid are highly associated with CDAD and should be avoided when possible in patients who have had recent CDAD infections. Although amoxicillin-clavulanic acid can be used to treat cystitis, it is more commonly administered for respiratory infections. (Choice D) Nitrofurantoin should not be used for men with cystitis as it does not reach reliable tissue concentrations and is less effective than other therapies if occult prostatitis is present. Educational objective: Patients with a history of Clostridium difficile-associated diarrhea (CDAD) should have careful antibiotic stewardship. Fluoroquinolones, clindamycin, and broad-spectrum penicillins/cephalosporins are associated with high rates of CDAD; therefore, alternate antibiotics with a lower risk of CDAD should be used when possible. __________ References: Clinical practices guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). (http://www.ncbi.nlm.nih.gov/pubmed/20307191) Community-associated Clostridium difficile infection and antibiotics: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23620467)

A 64-Year-Old Man with a History of Benign Prostate Hyperplasia