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?

Uncomplicated cystitis in a patient that is not pregnant.

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

C
Trimethoprim-sulfamethoxazole for 3 days

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

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

B
Due to common resistance in the community

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

A
Amoxicillin-clavulanate

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

C
They have lower teratogenicity

Discussion:

➡️Learn More⬅️:

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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