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PATIENT PRESENTATION

Chief Complaint

“Pain upon urination”

History of Present Illness

HR is a 42-year-old female who presents to your ambulatory care clinic complaining of foul-smelling urine and pain upon urination but has had no fevers. She describes having unprotected intercourse with her husband 2 nights prior to symptoms presenting and that this has happened twice before over the past 3 years. She states that she was treated with short courses of antibiotics for the prior two episodes with something called “Bactrim” and “Cipro” and her symptoms improved.

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Missing Information?

Evaluate:

Patient Database

Drug Therapy Problems

Care Plan (by Problem)

TARGETED QUESTIONS

  1. Would this patient be considered to have pyelonephritis, complicated cystitis, or uncomplicated cystitis and why?

    Hint: See Pathophysiology in PPP

  2. What risk factors does this patient have for uncomplicated cystitis

    Hint: See Clinical Presentation and Diagnosis in PPP

  3. How does her previous UTIs and antibiotic therapy impact selection of antibiotic therapy for her current symptomology?

    Hint: See Treatment and Table 82-2 in PPP

  4. How would you empirically treat this patient’s uncomplicated cystitis?

    Hint: See Treatment and Table 82-2 in PPP

  5. What non-pharmacologic interventions could be recommended for this patient to prevent recurrent UTIs?

    Hint: See Treatment in PPP

FOLLOW-UP

Based on culture and susceptibilities, how would you adjust your empiric treatment, if any?

Hint: See Tables 82-2 and 82-3 in PPP

CASE SUMMARY

Global Perspective

Antimicrobial resistance is on the rise and as such treatment guidelines for the management of uncomplicated lower tract cystitis was adjusted in 2010 by IDSA to recommend nitrofurantoin and fosfomycin as first line therapy. As a result, both agents’ utilization has significantly increased over the years. Both agents are an attractive option for the management of uncomplicated cystitis due to their ability to concentrate well at the site of infection, low propensity for collateral damage (e.g., Clostridiodes difficile infections) due to limited systemic absorption, and broad-spectrum of activity. However, both agents were commercialized prior to the FDA setting more stringent methodologic standards for drug approval. Thus, uncertainties remain regarding their clinically efficacy, especially for single dose fosfomycin, as meta-analyses of randomized controlled trails show similar efficacy of nitrofurantoin to other agents such as fluoroquinolones.

Thus, Huttner and colleagues conducted a randomized controlled trial to determine the effect of 5-Day nitrofurantoin vs single-dose fosfomycin on clinical resolution of uncomplicated lower urinary tract infection in women. The trial was multinational, included 513 women who were considered uncomplicated (i.e., non-pregnant and age ≥ 18) who had to have a positive urine dipstick, no known colonization, ...

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