What is the appropriate management for a patient who was recently hospitalized for sepsis, subsequently developed a urinary tract infection (UTI) treated with doxycycline (doxy), and now presents with dysuria and a reported allergy to doxycycline, having not completed the treatment course?

From the Guidelines

The patient's history of UTI, incomplete antibiotic treatment, and reported allergy to doxycycline necessitate a reevaluation of his antibiotic regimen, with consideration of alternative treatments such as amoxicillin plus an aminoglycoside or a second-generation cephalosporin plus an aminoglycoside, as recommended by the European Association of Urology guidelines 1. The patient is a male who was initially hospitalized approximately two weeks ago for sepsis. After improvement, he was discharged home but experienced recurrent symptoms two days later. Upon returning to the hospital, he was diagnosed with a urinary tract infection (UTI), received intravenous fluids, and was prescribed doxycycline before being discharged. On May 1,2025, the patient sought medical attention again for abdominal pain and was treated for constipation with Miralax. Today in clinic, the patient reports a suspected allergy to doxycycline, has not completed his prescribed antibiotic treatment, and is complaining of dysuria. Key points in the patient's history include:

• Recent hospitalization for sepsis
• Diagnosis of UTI and treatment with doxycycline
• Reported allergy to doxycycline
• Incomplete antibiotic treatment
• Persistent dysuria Given the patient's history of sepsis and current symptoms, it is crucial to manage his UTI effectively to prevent further complications. The European Association of Urology guidelines recommend using a combination of antibiotics, such as amoxicillin plus an aminoglycoside or a second-generation cephalosporin plus an aminoglycoside, for the treatment of complicated UTIs 1. Considerations for the patient's treatment include:
• Avoiding the use of ciprofloxacin and other fluoroquinolones due to potential resistance and side effects 1
• Managing any underlying urological abnormalities or complicating factors 1
• Obtaining a urine culture to guide targeted therapy and ensure effective treatment of the UTI.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

History of Present Illness

The patient was admitted to the hospital approximately two weeks ago due to sepsis, but showed improvement and was discharged home. However, symptoms recurred about two days ago, prompting a return to the hospital. Upon readmission, the patient was diagnosed with a urinary tract infection (UTI) and was treated with fluids and doxycycline before being sent home again 2.

Recent Symptoms and Treatment

On May 1,2025, the patient returned to the hospital with abdominal pain and was treated for constipation with miralax. During a clinic visit, the patient reported concerns about being allergic to doxycycline, although the treatment for the UTI had not been completed, as evidenced by ongoing dysuria 2.

Clinical Considerations

• The patient's UTI diagnosis and treatment with doxycycline are consistent with guidelines for managing urinary tract infections, which recommend the use of antibiotics such as nitrofurantoin, fosfomycin, or trimethoprim-sulfamethoxazole as first-line treatments 2.
• The choice of doxycycline may be appropriate depending on the specific circumstances of the patient's infection and local resistance patterns, although fluoroquinolones like levofloxacin and ciprofloxacin are also commonly used for UTIs 3, 4, 5.
• Patient concerns about medication allergies should be taken seriously and investigated further to ensure safe and effective treatment.
• The patient's recurrent visits to the hospital may be related to factors such as uncertainty about their condition, perceived inability to access timely follow-up care, or convenience, as suggested by studies examining patient perspectives on return visits to the emergency department 6.

Key Points

• The patient has a history of sepsis and recent UTI diagnosis and treatment.
• Ongoing symptoms such as dysuria indicate that the UTI may not be fully resolved.
• Patient-reported allergy concerns need to be addressed to determine the best course of treatment.
• Consideration of patient preferences and access to care may help reduce recurrent hospital visits.