What are the next steps for workup and treatment in a patient with a negative urine culture but urinalysis (UA) showing signs of infection, now presenting with hematuria (pink-red urine) and dysuria (painful urination)?

From the Guidelines

For a patient with negative urine culture but UA showing infection signs, now with hematuria and dysuria, I recommend a thorough workup to rule out underlying conditions such as interstitial cystitis/bladder pain syndrome (IC/BPS), bladder cancer, or stones, while empirically treating for possible infection. The patient's symptoms of hematuria and dysuria, despite a negative urine culture, warrant further investigation 1. A careful history, physical examination, and laboratory examination should be performed to document basic symptoms and exclude infections or other confusable disorders 1.

Next Steps for Workup

• Repeat urinalysis and culture to detect possible fastidious organisms or lower levels of bacteria that may not have been identified initially 1
• Consider STI testing for Chlamydia and Gonorrhea, especially in sexually active patients
• Imaging with renal ultrasound or CT urogram to evaluate for stones, masses, or structural abnormalities that could explain the hematuria 1
• A proper hematuria workup should be performed, including a brief neurological exam to rule out an occult neurologic problem and an evaluation for incomplete bladder emptying 1

Treatment Considerations

• Empiric antibiotic treatment may be considered while awaiting further evaluation, with options such as nitrofurantoin or trimethoprim-sulfamethoxazole 1
• Ensure adequate hydration and consider phenazopyridine for symptom relief while awaiting definitive diagnosis
• If symptoms persist despite treatment, referral to urology for cystoscopy may be necessary to directly visualize the bladder and urethra 1

The discrepancy between the patient's symptomatic presentation and negative culture could be due to various factors, including prior antibiotic use, inadequate sample collection, or non-infectious causes like IC/BPS 1. It is essential to approach this patient with a thorough and systematic evaluation to determine the underlying cause of their symptoms and provide appropriate treatment.

From the Research

Next Steps for Workup and Treatment

The patient presents with a negative urine culture but urinalysis (UA) showing signs of infection, now presenting with hematuria (pink-red urine) and dysuria (painful urination). The following steps can be considered for workup and treatment:

• Re-evaluate the patient's symptoms and medical history to determine the cause of the hematuria and dysuria 2
• Consider ordering additional tests, such as a repeat urine culture, imaging studies (e.g., ultrasound, CT scan), or cystoscopy to rule out other conditions that may be causing the symptoms 2
• If the patient's symptoms persist, consider treating for a urinary tract infection (UTI) with a broad-spectrum antibiotic, such as nitrofurantoin, fosfomycin, or pivmecillinam, while awaiting culture results 3
• If the patient has a history of recurrent UTIs or is at risk for infections with extended-spectrum β-lactamases (ESBLs)-producing Enterobacteriales, consider using second-line options, such as oral cephalosporins or fluoroquinolones 3

Antibiotic Treatment Options

The choice of antibiotic treatment will depend on the suspected cause of the infection and the patient's medical history. Some options to consider include:

• Nitrofurantoin, fosfomycin, or pivmecillinam for uncomplicated UTIs 3
• Oral cephalosporins, such as cephalexin or cefixime, for more complicated UTIs 3
• Fluoroquinolones, such as ciprofloxacin or levofloxacin, for UTIs caused by ESBLs-producing Enterobacteriales 3
• Parenteral treatment options, such as piperacillin-tazobactam or carbapenems, for severe or complicated UTIs 3

Considerations for Antibiotic Resistance

When selecting an antibiotic, it is essential to consider the risk of antibiotic resistance. Factors that increase the risk of resistance include:

• Recent use of antibiotics 4
• History of UTIs or other infections 4
• Presence of underlying medical conditions, such as diabetes or immunosuppression 4
• Use of urinary catheters 5

Monitoring and Follow-up

The patient should be monitored closely for signs of improvement or worsening of symptoms. Follow-up appointments should be scheduled to:

• Review culture results and adjust antibiotic treatment as needed 6
• Assess the patient's response to treatment and adjust the treatment plan as needed 2
• Rule out other conditions that may be causing the symptoms 2