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Urinary Frequency, Dysuria, Urgency Post Starting SGLT2 Inhibitor – Provider Quiz – Medicine

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Background:

35-year-old female recently started on an SGLT2 inhibitor for chronic kidney disease presents with dysuria, frequency, and urgency for 3 days. Urine studies are positive for nitrites and leukocyte esterase. The patient is not pregnant. The patient is a type 2 diabetic. The patient does not have candida in the urine. The resistance rate of trimethoprim-sulfa in the community is low.

Please answer the following questions:

What is the diagnosis?

What is the most appropriate treatment for uncomplicated cystitis in the above setting?
A
Fosfomycin single dose
B
Nitrofurantoin for 5 days
C
Trimethoprim-sulfamethoxazole for 3 days
D
Ciprofloxacin for 7 days


Which pathogen is NOT commonly implicated in cystitis?
A
Escherichia coli
B
Proteus species
C
Klebsiella species
D
Pseudomonas aeruginosa

Why should trimethoprim-sulfamethoxazole not be chosen as first-line therapy in areas with a high local resistance rate?
A
Due to severe side effects
B
Due to common resistance in the community
C
Due to high cost
D
Due to limited availability in pharmacies

Which type of antibiotics is not preferred as a first-line treatment for uncomplicated cystitis in nonpregnant individuals?
A
Amoxicillin-clavulanate
B
Trimethoprim-sulfamethoxazole
C
Oral cephalosporins
D
Fluoroquinolones

Why are β-lactam antibiotics commonly used to treat cystitis in pregnant patients?
A
They have higher efficacy than other agents
B
They are contraindicated in pregnant patients
C
They have lower teratogenicity
D
They are the first-line treatment for cystitis

Discussion:

Treatment Options for Uncomplicated Cystitis

Trimethoprim-Sulfamethoxazole

  • Recommended as a 3-day course for uncomplicated cystitis.
  • Effective against common pathogens like Escherichia coli, Proteus species, Klebsiella species, and Staphylococcus saprophyticus.
  • Short-course therapy with narrow-spectrum antibiotics is preferred to minimize drug toxicity and resistance.
  • First-line empiric treatment options include a 3-day course of trimethoprim-sulfamethoxazole, a 5-day course of nitrofurantoin, and a single dose of fosfomycin.
  • Trimethoprim-sulfamethoxazole resistance in E. coli should be based on local resistance rates.

β-Lactam Antibiotics

  • Not preferred as first-line agents for uncomplicated cystitis due to decreased efficacy.
  • Can be used as an alternative if first-line agents are contraindicated, especially in pregnant patients.
  • β-Lactams are commonly used in pregnant patients because of teratogenicity concerns with other agents.

Fluoroquinolones

  • Considered an acceptable alternative treatment for uncomplicated cystitis but not first-line because of adverse effects and increased antimicrobial resistance.

Nitrofurantoin

  • Another preferred treatment option for uncomplicated cystitis in nonpregnant persons.
  • Concentrates well in urine with limited systemic penetration, reducing effects on the microbiome and systemic resistance development.
  • Requires a 5-day course for therapeutic effect.
  • Caution is needed when using nitrofurantoin in CKD. When the patient reaches stage 3B (eGFR 30 to 44), a 3 to 7 day course may be used if indicated. Monitor for signs of hepatic, neurologic, pulmonary, and gastrointestinal side effects.

Inspiration: Uncomplicated Urinary Tract Infections, National Library of Medicine

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