What is the best course of action for a female patient with recurrent urinary frequency, urgency, and dysuria after completing Bactrim (Trimethoprim/Sulfamethoxazole)?

From the Guidelines

I strongly recommend starting the patient on nitrofurantoin macrocrystals 100 mg twice daily for 5 days for recurrent uncomplicated urinary tract infection, as it is a first-line treatment option according to the most recent guidelines. This patient's presentation of urinary frequency, urgency, and dysuria without systemic symptoms like fever or back pain is consistent with a recurrent uncomplicated UTI, especially given her recent similar episode that resolved with antibiotics. Since her previous infection resolved completely before recurring, this represents a reinfection rather than a relapse.

• The European Association of Urology guidelines on urological infections, published in 2024 1, suggest nitrofurantoin macrocrystals as a first-line treatment option for uncomplicated cystitis in women.
• The patient should be advised to complete the full course even if symptoms improve, drink plenty of fluids, and return if symptoms worsen or don't improve within 48 hours.
• If she experiences multiple recurrences (3 or more per year), further evaluation with urine culture and possibly imaging would be warranted to rule out anatomical abnormalities or resistant organisms, as recommended by the AUA/CUA/SUFU guideline on recurrent uncomplicated urinary tract infections in women 2.
• Preventive measures like urinating after intercourse and wiping front to back may help prevent future infections.
• It is also important to consider the local resistance pattern and adjust the treatment accordingly, as suggested by the European Association of Urology guidelines 1.

From the Research

Patient Presentation

The patient is a 53-year-old female presenting with urinary frequency, urgency, and dysuria that developed yesterday. She has a history of similar symptoms 2 weeks ago, which resolved after completing a course of antibiotics.

Treatment Options

• The patient is being started on Bactrim (trimethoprim-sulfamethoxazole) 3, 4, 5.
• However, studies suggest that trimethoprim-sulfamethoxazole may not be the best option due to increasing antimicrobial resistance 3, 4, 5.
• Alternative treatment options for uncomplicated urinary tract infections include nitrofurantoin, fosfomycin, and pivmecillinam 3, 4.
• Fluoroquinolones may be reserved for more invasive infections 4.

Considerations

• The patient's recent exposure to antibiotics may increase the risk of resistance 3, 4, 5.
• Local susceptibility patterns and individualized assessment of risk factors for resistance are essential in determining appropriate empiric antibiotic therapy 3, 4.
• The patient's symptoms and medical history should be taken into account when selecting an antibiotic regimen 6, 7.

Antibiotic Resistance

• High rates of resistance to trimethoprim-sulfamethoxazole and ciprofloxacin have been reported 3, 4, 5.
• The use of new antimicrobials should be done wisely to avoid resistance development 3.
• Surveillance of antimicrobial resistance among uropathogens is crucial in guiding treatment decisions 5.