A 26-year-old woman phones after business hours to speak to the on-call provider due to 2 days of burning urination. The patient's urine has also been cloudy, and she has had to urinate every 2 hours. She has had no abdominal or flank pain, fever, chills, or vaginal or urethral discharge. Approximately a year ago, the patient had uncomplicated cystitis that was treated with an antibiotic. She has been sexually active with 1 partner for 6 years. Her last menstrual period was 2 days ago. The patient has a copper-containing intrauterine device for contraception. She has no drug allergies. What is the best next step in management of this patient?

Question

A 26-year-old woman phones after business hours to speak to the on-call provider due to 2 days of burning urination.  The patient's urine has also been cloudy, and she has had to urinate every 2 hours.  She has had no abdominal or flank pain, fever, chills, or vaginal or urethral discharge.  Approximately a year ago, the patient had uncomplicated cystitis that was treated with an antibiotic.  She has been sexually active with 1 partner for 6 years.  Her last menstrual period was 2 days ago.  The patient has a copper-containing intrauterine device for contraception.  She has no drug allergies.  What is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Acute, uncomplicated cystitis is common in women due to the proximity between the anus and vaginal introitus and the short length of the female urethra. Most cases are due to fecal flora, particularly Escherichia coli (75%-90%). The risk is greatest in those with recent sexual activity or a history of urinary tract infection. Manifestations include dysuria, urinary frequency/urgency, hematuria, and suprapubic pain. History alone (eg, phone consultation) is usually sufficient for diagnosis. However, physical examination and urine culture are required for those who are likely to be pregnant (eg, no contraception, no recent menstrual period) or who likely have pyelonephritis (eg, fever, chills, flank pain) or vaginal infection (eg, pruritus, discharge) (Choices A, D, and E). Treatment with empiric trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days cures >90% of cases; this common first-line therapy is employed in areas in which TMP-SMX resistance rates are either unknown or <20%. Five days of nitrofurantoin is another common first-line agent. (Choice B) Ciprofloxacin is first-line therapy for acute, uncomplicated pyelonephritis. However, this agent is not routinely used as a first-line therapy for acute, uncomplicated cystitis due to the risk of collateral damage (eg, colonization with multidrug-resistant organisms) and the fact that other, narrower-spectrum medications are highly effective. Educational objective: Patients with suspected acute, uncomplicated cystitis are often treated empirically with nitrofurantoin or trimethoprim-sulfamethoxazole without additional testing (eg, urine culture) or evaluation.

A 26-Year-Old Woman Phones After Business Hours to Speak to the On-Call