A 48-year-old woman comes to the emergency department due to urinary frequency, burning pain on urination, severe nausea, and weakness. The patient has a history of type 2 diabetes mellitus treated with metformin. Her last menstrual period was a year ago, and she is not sexually active. Temperature is 38.3 C (101 F), blood pressure is 120/76 mm Hg, pulse is 95/min, and respirations are 14/min. The patient is obese. Mild costovertebral angle tenderness is present. Laboratory results are as follows: Urinalysis shows many white blood cells. Intravenous ceftriaxone is started. Two days later, the patient feels better, is eating well, and is afebrile. Urine culture results show Escherichia coli sensitive to ceftriaxone, gentamicin, ciprofloxacin, and trimethoprim-sulfamethoxazole. Which of the following is the most appropriate next step in management of this patient?

Question

A 48-year-old woman comes to the emergency department due to urinary frequency, burning pain on urination, severe nausea, and weakness.  The patient has a history of type 2 diabetes mellitus treated with metformin.  Her last menstrual period was a year ago, and she is not sexually active.  Temperature is 38.3 C (101 F), blood pressure is 120/76 mm Hg, pulse is 95/min, and respirations are 14/min.  The patient is obese.  Mild costovertebral angle tenderness is present.  Laboratory results are as follows:  Urinalysis shows many white blood cells.  Intravenous ceftriaxone is started.  Two days later, the patient feels better, is eating well, and is afebrile.  Urine culture results show Escherichia coli sensitive to ceftriaxone, gentamicin, ciprofloxacin, and trimethoprim-sulfamethoxazole.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d477_7c11_bc81_d903e7f64c62_MD0003_00 This patient with dysuria, pyuria, fever, and costovertebral angle tenderness has pyelonephritis. Management of pyelonephritis is guided by the clinical picture and comorbid conditions. Those with vomiting, older age, sepsis, and certain medical conditions (eg, diabetes mellitus, urinary obstruction) require hospitalization and intravenous antibiotics due to a higher risk of treatment failure with outpatient oral antibiotics. After 48 hours of symptomatic improvement, most hospitalized patients can be transitioned to culture-guided oral antimicrobials. This patient with an Escherichia coli urinary infection sensitive to 2 oral agents can be switched to oral trimethoprim-sulfamethoxazole (a narrower-spectrum antibiotic than ciprofloxacin) and discharged. (Choices A and B) This patient requires cessation of intravenous ceftriaxone as her symptoms are improved at 48 hours and urine culture shows sensitivity to oral antimicrobials. Adding ciprofloxacin without discontinuing ceftriaxone would not be recommended. (Choice C) Pyelonephritis is a serious infection and usually requires 7-14 (not 3) days of antibiotics. (Choice D) Intravenous gentamicin is occasionally used for pyelonephritis; however, this patient had a resolution of symptoms with ceftriaxone and therefore does not require an additional intravenous antimicrobial. She should be transitioned to an oral antibiotic. Educational objective: Patients with pyelonephritis who are vomiting, of older age, or septic or who have certain comorbidities (eg, diabetes mellitus, urinary obstruction) typically require hospitalization and intravenous therapy. Most hospitalized patients can be transitioned to culture-guided oral antibiotics if symptoms are improved at 48 hours. References: Diagnosis and treatment of acute pyelonephritis in women. (http://www.ncbi.nlm.nih.gov/pubmed/21888302) International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of American and the European Society for Microbiology and Infectious Diseases. (http://www.ncbi.nlm.nih.gov/pubmed/21292654)

A 48-Year-Old Woman Comes to the Emergency Department Due to Urinary