A 31-year-old female presented with painful urination, dysuria, urgency, and frequency. Her history was notable for a previous urinary tract infection. On examination, she was afebrile with no abdominal tenderness. A urinalysis showed bacteria and red blood cells. She was diagnosed with an uncomplicated urinary tract infection and prescribed levofloxacin and etoricoxib. Patients with uncomplicated infections typically improve with short-term antibiotic treatment, while those with recurrent infections may require long-term prophylaxis.
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2. M.R. 31 F Single From Pasig Chief complaint: Painful urination
3. Few hours PTC, Dysuria Urgency Frequency Low back pain No hematuria No hypogastric pain No suprapubic pain No fever No consult No medications History of Present Illness
4. No vaginal discharge No vaginal irritation No cough/ cold No fever No loose stools No chest pain No dizziness No palpitations Review of Systems
5. UTI (early this year) Treated, resolved No past surgeries and hospitalizations No hypertension, diabetes, asthma Allergies to Amoxicillin Past Medical History
16. Extremities Full pulses No edema, no cyanosis Good turgor No rashes, no lesions Equally distributed hair No clubbing CRT <2sec
17. Salient Features 31 female Painful urination Acute presentation of: Dysuria Urgency Frequency Low back pain No hematuria No hypogastric pain No suprapubic pain No fever Previous history of UTI Afebrile Soft, non-tender abdomen No CVA tenderness Sexual history?
19. Clinically, acute uncomplicated cystitis is suspected in non-pregnant women, 18-64 years old, presenting with dysuria, frequency, or gross hematuria, with or without back pain. Risk factors for complicated urinary tract infection must be absent. Acute uncomplicated cystitis The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
20. Etiology The most common agents are the gram-negative bacilli. Escherichia coli Proteus Klebsiella Enterobacter Serratia Pseudomonas
22. Pathogenesis urinary tract should be viewed as a single anatomic unit bacteria gain access to the bladder via the urethra alteration of the normal vaginal flora by antibiotics, other genital infections, or contraceptives (especially spermicide) Loss of the normally dominant H2O2-producing lactobacilli in the vaginal flora facilitate colonization by E. coli.
23. Pathogenesis Why females? proximity to the anus, its short length (~4 cm), and its termination beneath the labia Found in 2-8% of pregnant women decreased ureteral tone, decreased ureteral peristalsis, and temporary incompetence of the vesicoureteral valves How about males? Uncommon; entertain a possibility of heterosexual or homosexual rectal intercourse urethral obstruction due to prostatic hypertrophy
24. Pathogenesis Obstruction? Any impediment to the free flow of urine (tumor, stricture, stone, or prostatic hypertrophy) results in hydronephrosis Dysfunction? Interference with bladder enervation, as in spinal cord injury, tabesdorsalis, multiple sclerosis, diabetes, and other diseases Reflux? common among children with anatomic abnormalities of the urinary tract as well as among children with anatomically normal but infected urinary tracts
26. Clinical Presentation Urethritis 30% of women with acute dysuria, frequency, and pyuria have midstream urine cultures that show either no growth or insignificant bacterial growth Distinguish between sexually-transmitted pathogens and low count E.coli or staphylococcal infection
28. Diagnostics In women who present with additional symptoms such as vaginal discharge or vaginal irritation, either a standard urine microscopy or dipstick for LE and nitrites can be done to confirm the diagnosis Pre-treatment urine culture and sensitivity is notrecommended Standard urine microscopy and dipstick leukocyte esterase (LE) and nitrite tests are not prerequisites for treatment The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
29. What was done? Urinalysis Light yellow Turbid pH 7.0 SG 1.015 RBC +3 (39/hpf) Protein +1 WBC +3 (260/hpf) Epithelial 3/hpf Casts 0/hpf Bacteria 251/hpf The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
30. Therapy ANTIBIOTICS THAT CAN BE USED FOR ACUTE UNCOMPLICATED CYSTITIS The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
31. What was given? Levofloxacin 500mg OD x 7 days Etoricoxib (Arcoxia) 12 mg PRN The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
32. Ampicillin and amoxicillin should not be used Three-day therapy is the recommended duration of treatment except for nitrofurantoin, which must be given for 7 days. Post-treatment urine culture not recommended The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
33. It didn’t work! Now what? Patients whose symptoms worsen or do not improve after 3 days should have a urine culture and the antibiotic should be empirically changed, pending result of sensitivity testing Patients whose symptoms fail to resolve after the 7- day treatment should be managed as a complicated urinary tract infection The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
34. Prognosis In patients with uncomplicated cystitis or pyelonephritis, treatment ordinarily results in complete resolution of symptoms It rarely progresses to renal functional impairment and chronic renal disease. Repeated upper tract infections often represent relapse rather than reinfection Repeated symptomatic UTIs in children and in adults with obstructive uropathy, neurogenic bladder, structural renal disease, or diabetes progress to chronic renal disease with unusual frequency
35. Who needs prophylaxis? Women who experience frequent symptomatic UTIs (>3 per year on average) are candidates for long-term administration of low-dose antibiotics Daily or thrice-weekly administration of a single dose of TMP-SMX (80/400 mg), TMP alone (100 mg), or nitrofurantoin (50 mg) Norfloxacin and other fluoroquinolones Men with chronic prostatitis; patients undergoing prostatectomy, both during the operation and in the postoperative period; and pregnant women with asymptomatic bacteriuria
38. References The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004 Harrison’s Principles of Internal Medicine, 16thed
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Editor's Notes
Esch- erichia coli causes 80% of acute infections in patients without cath- eters, urologic abnormalities, or calculi.
Serratiaand Pseudomonas, assume increasing im- portance in recurrent infections and in infections associated with uro- logic manipulation, calculi, or obstruction
normally colonized by diphtheroids, streptococcal species, lactobacilli, and staphylococcal species
Dysfunction use of catheters for bladder drainage and is favored by the prolonged stasis of urine in the bladder.