Question

A 22 year old black woman present with complaints of burning and frequency of urination for the past 2 to 3 days. It is getting worse. She feels she has to void, rushes to the bathroom and then is only able to void a small amount. it is painful. There is no sign of blood in the urine. She denies fever, chills, diarrhea, nausea, vomiting or vaginal discharge.

" I have to rush to the bathroom, and it hurts when I urinate".

Physical Ex:

Essentially unremarkable. Negative suprapubic tenderness: negative costovertebral angle tenderness. Negative abdominal pain and benign abdominal exam. Negative back pain. Afebrile. Vital signs normal. No complaints of vaginal discharge. Uranalysis shows+ WBCs, trace RBCs.

• What is your management plan for this patient? Would you prescribe an antibiotic prior to the return of the culture and sensitivity? If you prescribe an antibiotic, which one would you choose and why?
• If this were a recurrent problem, would your approach and treatment differ? Why?
• Would this differ if this patient is pregnant? How would you approach the diagnosis and management?
• Would any complementary therapies be appropriate for this patient? If so, which ones specifically? Cite evidence from the literature to support their use.

Answer 1

Answers:-

This is a case of Acute Urinary Tract Infection (UTI).

—MANAGEMENT PLAN FOR THE PATIENT:-

Diagnosis

Tests and procedures used to diagnose urinary tract infections include:

• Analyzing a urine sample. Your doctor may ask for a urine sample for lab analysis to look for white blood cells, red blood cells or bacteria. To avoid potential contamination of the sample, you may be instructed to first wipe your genital area with an antiseptic pad and to collect the urine midstream.
• Growing urinary tract bacteria in a lab. Lab analysis of the urine is sometimes followed by a urine culture. This test tells your doctor what bacteria are causing your infection and which medications will be most effective.
• Creating images of your urinary tract. If you are having frequent infections that your doctor thinks may be caused by an abnormality in your urinary tract, you may have an ultrasound, a computerized tomography (CT) scan or magnetic resonance imaging (MRI). Your doctor may also use a contrast dye to highlight structures in your urinary tract.
• Using a scope to see inside your bladder. If you have recurrent UTIs, your doctor may perform a cystoscopy, using a long, thin tube with a lens (cystoscope) to see inside your urethra and bladder. The cystoscope is inserted in your urethra and passed through to your bladder.

Urinary tract infections can be painful, but you can take steps to ease your discomfort until antibiotics treat the infection. Follow these tips:

• Drink plenty of water. Water helps to dilute your urine and flush out bacteria.
• Avoid drinks that may irritate your bladder. Avoid coffee, alcohol, and soft drinks containing citrus juices or caffeine until your infection has cleared. They can irritate your bladder and tend to aggravate your frequent or urgent need to urinate.
• Use a heating pad. Apply a warm, but not hot, heating pad to your abdomen to minimize bladder pressure or discomfort.

If you have a history of frequent urinary tract infections, you may be given a prescription for antibiotics that you would take at the first onset of symptoms. Other patients may be given antibiotics to take every day, every other day, or after sexual intercourse to prevent the infection.

—YES, WE SHOULD PRESCRIBE AN ANTIBIOTIC PRIOR TO THE RETURN OF THE CULTURE AND SENSITIVITY.

It is done for prophylaxis of the UTI mad and to relieve from the symptoms.

The best way to treat a UTI -- and to relieve symptoms like pain, burning, and an urgent need to pee -- is with antibiotics. These medications kill bacteria that cause the infection.

—The preferred Antibiotic is COTIRMOXAZOLE ( IT IS A COMBINATION OF SULFAMETHOXAZOLE AND TRIMETHOPRIM).

REASON:

Urinary tract infections are caused by microorganisms — usually bacteria — that enter the urethra and bladder, causing inflammation and infection. Though a UTI most commonly happens in the urethra and bladder, bacteria can also travel up the ureters and infect your kidneys. COTIRMOXAZOLE attains high concentration in urinary tract, therefore it is the most preferred drug.

—RECURRENT UTI:-

Women with recurrent symptomatic urinary tract infections can be treated with continuous or postcoital prophylactic antibiotics; other treatment options include self-started antibiotics, cranberry products, and behavioral modification. Patients at risk of complicated urinary tract infections are best managed with broad-spectrum antibiotics initially, urine culture to guide subsequent therapy, and renal imaging studies if structural abnormalities are suspected.

1) Continuous low-dose antibiotics

Continuous low-dose antibiotic prophylaxis is effective at preventing UTIs.Because the optimal prophylactic antibiotic is unknown, allergies, prior susceptibility, local resistance patterns, cost and side effects should determine the antibiotic choice. Nitrofurantoin followed by cephalexin display the highest rates of treatment dropout.

After discontinuing prophylaxis, women were found to revert to their previous frequency of UTI.

2) Postcoital antibiotics

Postcoital antibiotic prophylaxis is another effective measure to prevent UTIs in women when sexual activity usually precedes UTI. A further randomized controlled trial found no difference in the efficacy of post-intercourse and daily oral ciprofloxacin with 70 patients in the post-intercourse and 65 in the daily group.

3) Self-start antibiotics

Self-start antibiotic therapy is an additional option for women with the ability to recognize UTI symptomatically and start antibiotics. Patients should be given prescriptions for a 3-day treatment dose of antibiotics. Patients are advised to contact a health care provider if symptoms do not resolve within 48 hours for treatment based on culture and sensitivity.

—DIAGNOSIS AND TREATMENT IN PREGNANT FEMALES:-

Urinary tract infections are common during pregnancy, and the most common causative organism is Escherichia coli. Asymptomatic bacteriuria can lead to the development of cystitis or pyelonephritis. All pregnant women should be screened for bacteriuria and subsequently treated with antibiotics such as nitrofurantoin, sulfisoxazole or cephalexin. Ampicillin should no longer be used in the treatment of asymptomatic bacteriuria because of high rates of resistance. Pyelonephritis can be a life-threatening illness, with increased risk of perinatal and neonatal morbidity. Recurrent infections are common during pregnancy and require prophylactic treatment. Pregnant women with urinary group B streptococcal infection should be treated and should receive intrapartum prophylactic therapy.

Antibiotic Choices for Treatment of UTIs During Pregnancy:

ANTIBIOTIC	PREGNANCY CATEGORY	DOSAGE
Cephalexin (Keflex)	B	250 mg two or four times daily
Erythromycin	B	250 to 500 mg four times daily
Nitrofurantoin (Macrodantin)	B	50 to 100 mg four times daily
Sulfisoxazole (Gantrisin)	C*	1 g four times daily
Amoxicillin-clavulanic acid (Augmentin)	B	250 mg four times daily
Fosfomycin (Monurol)	B	One 3-g sachet
Trimethoprim-sulfamethoxazole (Bactrim)	C†	160/180 mg twice daily

—COMPLEMENTARY THERAPIES:-

1. Stay hydrated. Share on Pinterest Drinking water regularly may help to treat a UTI.
2. Urinate when the need arises.
3. Drink cranberry juice.
4. Use probiotics.
5. Get enough vitamin C.
6. Wipe from front to back.
7. Practice good sexual hygiene.
8. Drinking unsweetened cranberry juice is one of the most well-known natural remedies for urinary tract infections. Cranberries work by preventing bacteria from adhering to the urinary tract, thus preventing infection.