From the Guidelines
For a patient with HIV presenting with dysuria and a mildly positive leukocyte esterase with otherwise negative urinalysis findings, I recommend empiric treatment for urethritis with a single dose of ceftriaxone 500mg intramuscularly plus doxycycline 100mg orally twice daily for 7 days. This approach is based on the most recent and highest quality evidence available, which emphasizes the importance of covering common causes of urethritis in HIV patients, such as gonorrhea and chlamydia 1. The positive leukocyte esterase indicates inflammation in the urinary tract, while the absence of nitrites or bacteria suggests a non-bacterial urinary tract infection or urethritis rather than cystitis. Key considerations in managing such patients include:
- Obtaining urine nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia before starting treatment, though therapy shouldn't be delayed while awaiting results 1.
- Counseling the patient on safe sex practices.
- Notifying and treating partners from the past 60 days.
- Considering further evaluation for other causes such as Mycoplasma genitalium, Trichomonas, or drug-resistant organisms if symptoms persist after treatment 1. Given the patient's HIV status and the presence of dysuria with a mildly positive leukocyte esterase, it's crucial to prioritize the treatment of potential sexually transmitted infections, which can present atypically in this population.
From the Research
Patient Profile
- The patient has HIV and is experiencing dysuria
- Urinalysis results show leukocyte esterase mildly positive, with all other items negative
Relevant Studies
- A study from 2009 2 found that the resistance rate for trimethoprim/sulfamethoxazole (TMP/SMX) was 34% in patients with urinary tract infections (UTIs), with all resistant microorganisms being E. coli
- Another study from 2016 3 found that among E. coli positive patients, resistance to TMP/SMX was the most common antibiotic resistance, and that fosfomycin could be a viable option for treatment
- A study from 1969 4 found that a combination of sulphamethoxazole and trimethoprim was effective in treating urinary infections, with a cure rate of 85% in one week after finishing treatment
- A review from 2005 5 highlighted the importance of considering antibiotic resistance patterns when choosing empiric therapy, and noted that inadequate or prolonged antibiotic administration may encourage the emergence of resistant bacteria
- A study from 2020 6 found that prior urinary infection/colonisation with SXT-resistant Enterobacteriaceae and SXT use within the past 12 months were predictors of SXT resistance among urinary isolates
Treatment Considerations
- The patient's HIV status and dysuria symptoms should be taken into account when considering treatment options
- The mildly positive leukocyte esterase result suggests a possible urinary tract infection, but the negative results for other urinalysis items may indicate a need for further testing or evaluation
- The studies suggest that TMP/SMX may not be the best empiric treatment option due to high resistance rates, and that other antibiotics such as fosfomycin may be more effective
- The patient's medical history and prior antibiotic use should be considered when selecting a treatment option, as these factors may influence the likelihood of antibiotic resistance.