What are the next steps for a 67-year-old patient with persistent hematuria (blood in urine) and glycosuria (glucose in urine) despite antibiotic treatment for a urinary tract infection (UTI), presenting with mild back pain and foul-smelling urine?

From the Guidelines

The next steps for this 67-year-old patient should include prompt referral to a urologist and nephrologist for comprehensive evaluation, as the persistent hematuria and glycosuria despite antibiotic treatment suggest underlying conditions requiring investigation. The patient's symptoms, including mild back pain and foul-smelling urine, indicate a possible complicated urinary tract infection (UTI) or other underlying conditions such as kidney stones, tumors, or structural abnormalities 1.

Given the patient's age and persistent UTI symptoms, there is a significant risk for underlying diabetes, and the glycosuria warrants diabetes screening 1. The back pain could indicate pyelonephritis or kidney involvement requiring more aggressive treatment.

The patient should undergo:

• Urine culture with antibiotic sensitivity testing to identify appropriate antimicrobial therapy, typically a fluoroquinolone like ciprofloxacin 500mg twice daily for 7-14 days or trimethoprim-sulfamethoxazole 160/800mg twice daily for 7-14 days depending on sensitivity results 1
• Comprehensive blood work including complete blood count, comprehensive metabolic panel, HbA1c, and kidney function tests
• Imaging studies, such as a CT urogram or renal ultrasound, to evaluate for kidney stones, tumors, or structural abnormalities 1
• Increased fluid intake to 2-3 liters daily, avoidance of bladder irritants like caffeine and alcohol, and immediate return if fever, worsening pain, or systemic symptoms develop

This comprehensive approach is necessary because persistent hematuria in this age group can signal serious conditions, including malignancy, while the combination with glycosuria suggests metabolic issues requiring prompt attention 1.

From the Research

Next Steps for Patient Care

The patient, a 67-year-old with persistent hematuria and glycosuria despite antibiotic treatment for a UTI, presents with mild back pain and foul-smelling urine. Considering the evidence from recent studies, the following steps can be taken:

• Re-evaluation of UTI Treatment: Given that bacterial persistence in UTIs is a concern, especially in postmenopausal women 2, it may be necessary to reassess the antibiotic treatment regimen. The study suggests that fosfomycin could be effective in reducing bacterial persistence.
• Further Diagnostic Testing: Blood cultures may be useful in selected patients, particularly those with complicated UTIs or who are at risk of bacteremia 3. However, the decision to obtain blood cultures should be made on a case-by-case basis.
• Consideration of Non-antibiotic Prophylaxis: For patients with recurrent UTIs, non-antibiotic prophylaxis should be prioritized before antibiotic prophylaxis 4.
• Urinalysis and Culture: The diagnostic value of different urine tests for UTI should be considered, including bacterial culture, urine sediment microscopy, automated urinalysis, and routine urine dry chemical methods 5.
• Monitoring for Underlying Conditions: The presence of kidney stones or other underlying conditions may increase the risk of UTI 6. Therefore, monitoring for these conditions and addressing them promptly is essential.

Potential Underlying Causes

The patient's persistent hematuria and glycosuria despite antibiotic treatment may indicate an underlying condition that needs to be addressed. Potential causes include:

• Bacterial Persistence: As mentioned earlier, bacterial persistence in UTIs is a concern, especially in postmenopausal women 2.
• Kidney Stones: The presence of kidney stones may increase the risk of UTI 6.
• Other Underlying Conditions: Other underlying conditions, such as diabetes or kidney disease, may also contribute to the patient's symptoms.

Additional Considerations

When managing the patient's care, the following considerations should be kept in mind:

• Antibiotic Resistance: The overuse or misuse of antibiotics can contribute to antibiotic resistance 2.
• Patient Education: Patient education on UTI prevention and management is essential, particularly for those with recurrent UTIs 4.
• Follow-up Care: Regular follow-up care is necessary to monitor the patient's condition and adjust the treatment plan as needed.