From the Guidelines
For patients presenting with dysuria and a negative urinalysis, symptomatic therapy with ibuprofen may be considered as an alternative to antimicrobial treatment, in consultation with the individual patient, as suggested by the European Association of Urology guidelines 1. This approach is based on the understanding that most cases of uncomplicated cystitis are caused by Escherichia coli, but urine analysis leads to only a minimal increase in diagnostic accuracy in patients with typical symptoms 1. When considering treatment, it's essential to evaluate the patient's symptoms and medical history to determine the best course of action. Some key points to consider include:
- The patient's symptoms, such as dysuria, frequency, and urgency, to determine if they are consistent with uncomplicated cystitis 1
- The absence of vaginal discharge or other symptoms that may indicate a different condition 1
- The patient's medical history, including any previous urinary tract infections or other relevant conditions 1 If the diagnosis is unclear, dipstick analysis can increase the likelihood of a diagnosis of uncomplicated cystitis 1. However, for patients with mild to moderate symptoms, symptomatic therapy may be a suitable alternative to antimicrobial treatment 1. It's also important to note that routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1. In cases where symptoms persist or recur, a urine culture and antimicrobial susceptibility testing should be performed to guide further treatment 1.
From the Research
Treatment for Dysuria without Evidence of Negative Urinalysis
- The treatment for dysuria without evidence of negative urinalysis can be guided by the results of studies on urinary tract infections (UTIs) 2, 3, 4.
- According to a study published in 2020, the recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females is a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 2.
- Another study published in 2014 found that trimethoprim-sulfamethoxazole, nitrofurantoin monohydrate/macrocrystals, and fosfomycin trometamol are all appropriate first-line therapies for uncomplicated cystitis 3.
- A study published in 1977 noted that sulfonamides, trimethoprim-sulfamethoxazole, nitrofurantoin, and nalidixic acid are useful for treatment of uncomplicated lower urinary tract infections in an outpatient setting 4.
Predictive Value of Negative Urinalysis
- A negative urinalysis has a high predictive value for negative urine culture and absence of UTI in men with and without catheters 5.
- A study published in 2013 found that a negative urinalysis reliably excludes a catheter-associated UTI in the febrile, trauma ICU patient with a 100% negative predictive value 6.
- The predictive value of a negative urinalysis for absence of UTI is high, ranging from 99% to 100% in different studies 5, 6.
Treatment Options
- Treatment options for UTIs include nitrofurantoin, fosfomycin, pivmecillinam, fluoroquinolones, and β-lactams such as amoxicillin-clavulanate 2, 3.
- For UTIs caused by ESBL-producing Enterobacteriales, treatment options include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 2.
- Parenteral treatment options for UTIs due to ESBL-producing Enterobacteriales include piperacillin-tazobactam, carbapenems, and ceftazidime-avibactam 2.