A 25-year-old woman comes to the physician complaining of a 3-day history of burning with urination and increased urinary frequency. She has suprapubic discomfort but no unusual vaginal discharge. The patient has been sexually active and monogamous with her husband for the past 4 years. She has never been pregnant and uses condoms for contraception. Her last menstrual period was 2 weeks ago, and her last sexual encounter was 2 days ago. She takes no medications and has no known drug allergies. Her temperature is 37.1 C (98.9 F), blood pressure is 110/70 mm Hg, pulse is 68/min, and respirations are 15/min. Examination shows suprapubic tenderness without flank tenderness. The rest of the examination is within normal limits. Her urine pregnancy test is negative. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 25-year-old woman comes to the physician complaining of a 3-day history of burning with urination and increased urinary frequency.  She has suprapubic discomfort but no unusual vaginal discharge.  The patient has been sexually active and monogamous with her husband for the past 4 years.  She has never been pregnant and uses condoms for contraception.  Her last menstrual period was 2 weeks ago, and her last sexual encounter was 2 days ago.  She takes no medications and has no known drug allergies.  Her temperature is 37.1 C (98.9 F), blood pressure is 110/70 mm Hg, pulse is 68/min, and respirations are 15/min.  Examination shows suprapubic tenderness without flank tenderness.  The rest of the examination is within normal limits.  Her urine pregnancy test is negative.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d503_8f75_bc81_49805461a592_MD0003_00 This patient's clinical presentation (dysuria, urinary frequency, suprapubic tenderness) suggests uncomplicated cystitis. Uncomplicated cystitis commonly occurs in otherwise healthy patients and has a low risk of treatment failure. In patients with suggestive clinical findings (eg, dysuria, urgency), urinalysis will confirm the diagnosis and patients can be treated without a urine culture. Culture is reserved for those who fail initial therapy (Choice E). Preferred treatment options include trimethoprim-sulfamethoxazole (3 days), nitrofurantoin (5 days), and fosfomycin (single dose). Fluoroquinolones are also effective but are typically reserved for patients who cannot take the above options (eg, sulfa allergy) or for settings with high local resistance rates (Choice C). Complicated cystitis refers to infections associated with factors that increase the risk of antibiotic resistance or treatment failure. Such factors include diabetes, chronic kidney disease, pregnancy, immunocompromised state, or urinary tract obstruction; hospital-acquired infection; or infection associated with a procedure (eg, cystoscopy) or indwelling foreign body (eg, catheter, stent). These patients should have urine culture prior to therapy. Complicated cystitis in otherwise nonpregnant stable patients may be managed with oral fluoroquinolones, but more severe cases may require intravenous broad-spectrum antibiotics (eg, ceftriaxone) while awaiting culture results. Pyelonephritis (ie, urinary tract infection with fever and flank pain/tenderness) also requires urine culture prior to starting treatment. Nonpregnant stable patients with uncomplicated pyelonephritis can be treated with oral antibiotics (usually a fluoroquinolone), but unstable patients and those with complicated infection require intravenous antibiotics (eg, ceftriaxone). (Choice A) Intramuscular ceftriaxone with oral doxycycline is often used empirically for treating suspected chlamydial and/or gonococcal infections. Doxycycline is not reliably effective for cystitis, and oral medications are preferred over parenteral for uncomplicated cystitis. (Choice B) Amoxicillin is not recommended for empiric treatment of cystitis due to antibiotic resistance. Amoxicillin/clavulanate may be considered but is associated with significant side effects (eg, diarrhea). Educational objective: Uncomplicated cystitis commonly occurs in otherwise healthy patients and has a low risk of treatment failure. Urinalysis confirms the diagnosis. Patients can be treated without a urine culture, which may be done later in those who fail initial therapy. Oral trimethoprim/sulfamethoxazole, nitrofurantoin, and fosfomycin are effective first-line treatment options. References: Nitrofurantoin compares favorably to recommended agents as empirical treatment of uncomplicated urinary tract infections in a decision and cost analysis. (http://www.ncbi.nlm.nih.gov/pubmed/21576512) 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. (http://www.ncbi.nlm.nih.gov/pubmed/21292654)

A 25-Year-Old Woman Comes to the Physician Complaining of a 3-Day