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Question 12#

A 25-year-old woman complains of dysuria, frequency, and suprapubic pain. She has not had previous symptoms of dysuria and is not on antibiotics. She is sexually active and on birth control pills. She has no fever, vaginal discharge, or history of herpes infection. She denies back pain, nausea, or vomiting. On physical examination she appears well and has no costovertebral angle tenderness. A urinalysis shows 20 white blood cells per high power field. Which of the following statements is correct?

A. A 3-day regimen of trimethoprim-sulfamethoxazole is adequate therapy
B. Quantitative urine culture with antimicrobial sensitivity testing is mandatory
C. Obstruction resulting from renal stone should be ruled out by ultrasound
D. Low-dose antibiotic therapy should be prescribed while the patient remains sexually active
E. One dose of a parenteral antibiotic such as gentamicin should be given to prevent progression to pyelonephritis

Correct Answer is A

Comment:

The patient’s presentation strongly suggests acute uncomplicated cystitis. Although some physicians still perform urine culture and sensitivity on all such patients, it is generally considered practical and appropriate to treat with empiric antibiotic therapy. A 3-day regimen of trimethoprimsulfamethoxazole or fluoroquinolone, or a 5-day course of nitrofurantoin are the recommended regimens. Knowledge of local antibiotic resistance patterns can help choose among these three regimens. Workup for obstruction or kidney stone is not indicated in cystitis but may be necessary in the evaluation of pyelonephritis (especially recurrent disease). Low-dose antibiotic therapy has been used successfully in women with frequent (three or more per year) urinary tract infections. Although 10% to 20% of community-acquired UTIs may be resistant to one of the recommended oral regimens, patients may respond to the high antibiotic levels achieved in the urine. If this woman’s symptoms do not respond to oral antibiotics after a few days, culture-directed treatment would be recommended. Parenteral antibiotics are not recommended for uncomplicated cystitis.