What is the appropriate management for a 60-year-old female with suspected UTI, recurrent UTIs, and multiple comorbidities, including arthritis and vertigo, with complex care involving multiple specialists?

From the Guidelines

The 60-year-old female patient should be tested for a UTI today and treated locally due to her difficulty traveling to Lubbock to see her urologist, with empiric treatment guided by the most recent and highest quality study available 1. Given her history of recurrent UTIs, the most recent guideline from the American College of Radiology 1 suggests that a UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI, and recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months.

• The patient's symptoms and history are consistent with an uncomplicated UTI, and therefore, empiric treatment with nitrofurantoin 100mg twice daily for 5-7 days or trimethoprim-sulfamethoxazole DS twice daily for 3 days would be appropriate while awaiting culture results 1.
• Her ears should be examined today to address her complaints of popping and intermittent positional vertigo, which may indicate eustachian tube dysfunction possibly related to her nasal congestion.
• The patient should clarify her PCP situation by contacting her insurance company to confirm whether Dr. Payne or Dr. Little is her designated primary care physician, as this confusion may be affecting care coordination.
• She should be encouraged to keep her upcoming rheumatology appointment with Dr. Bushman next week for her arthritis flare.
• Additionally, a comprehensive medication review should be conducted to ensure there are no interactions between treatments prescribed by her multiple specialists (urology, cardiology, sleep medicine, gastroenterology, and rheumatology) 1.
• A care coordination plan should be established to improve communication between her numerous providers to prevent fragmentation of care and ensure all her medical issues are being appropriately addressed.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to empiric selection of therapy Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris

The patient can be treated with trimethoprim-sulfamethoxazole for a urinary tract infection if the infection is proven or strongly suspected to be caused by susceptible bacteria, such as Escherichia coli or Klebsiella species. It is recommended to use a single effective antibacterial agent for initial episodes of uncomplicated urinary tract infections 2.

From the Research

Patient Presentation

The patient is a 60-year-old female presenting with concerns of a urinary tract infection (UTI), which is significant given her history of recurrent UTIs. She reports seeing Dr. Payne as her primary care physician (PCP) but Dr. Little is listed on her insurance.

Medical History

• The patient has a history of recurrent UTIs
• She has arthritis that is currently flaring up
• She has missed multiple rheumatology appointments with Dr. Bushman
• She is experiencing intermittent positional vertigo lasting seconds
• She reports nasal congestion and ear popping

Current Requests

• The patient is requesting UTI testing and treatment locally due to difficulty traveling to Lubbock to see her urologist
• She would like her ears to be examined

Complicated Care

• The patient's care is complicated by multiple specialists, including:
  • Dr. Ownes (urology)
  • Dr. Ranganath (cardiology)
  • Dr. Dihenia (sleep medicine)
  • Dr. Kensing (GI)
  • Dr. Bushan (Rheumatology)
• There is confusion regarding her PCP (Dr. Payne vs. Dr. Little)

UTI Diagnosis and Treatment

• According to 3, sulfonamides, trimethoprim-sulfamethoxazole, nitrofurantoin, and nalidixic acid are effective for treating uncomplicated lower urinary tract infections
• 4 suggests that nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are first-line treatments for UTI, with minimal collateral damage and resistance
• 5 recommends trimethoprim-sulfamethoxazole, nitrofurantoin monohydrate/macrocrystals, and fosfomycin trometamol as appropriate first-line therapies for uncomplicated cystitis
• 6 and 7 emphasize the importance of diagnostic stewardship for UTI, including optimal use of urine cultures and reducing unnecessary antibiotic use

Considerations for Treatment

• The patient's history of recurrent UTIs and current symptoms should be taken into account when determining the best course of treatment
• The patient's difficulty traveling to see her urologist should be considered when deciding on local treatment options
• The patient's complicated care and multiple specialists should be coordinated to ensure comprehensive treatment