From the Guidelines
For a 50-year-old female with leukocytes in urinalysis (leuk on UA) accompanied by nausea and back pain, the most appropriate treatment is empiric antibiotics such as fluoroquinolones or cephalosporins, as recommended by the European Association of Urology guidelines 1. Given the symptoms of nausea and back pain, which are indicative of pyelonephritis 1, it is crucial to initiate treatment promptly to prevent complications. The patient's presentation with leukocytes in urinalysis supports the diagnosis of a urinary tract infection (UTI), likely pyelonephritis 1.
Key Considerations
- Urinalysis, including assessment of white and red blood cells and nitrite, is essential for routine diagnosis 1.
- A urine culture and antimicrobial susceptibility testing should be performed to guide treatment 1.
- Imaging studies, such as ultrasound, may be necessary to rule out urinary tract obstruction or renal stone disease 1.
Treatment Recommendations
- Fluoroquinolones, such as ciprofloxacin 500mg twice daily for 7 days, are recommended for oral empiric treatment of uncomplicated pyelonephritis 1.
- Cephalosporins, such as oral cephalosporins, can also be used, but achieve lower blood and urinary concentrations than the intravenous route 1.
- Patients with uncomplicated pyelonephritis requiring hospitalization should be treated initially with an intravenous antimicrobial regimen 1.
Symptom Management
- Increased fluid intake of 2-3 liters daily can help manage symptoms 1.
- Antiemetics, such as ondansetron 4mg every 6 hours, can be prescribed as needed for nausea 1.
- Acetaminophen or NSAIDs can help manage pain 1.
Monitoring and Follow-up
- The patient should seek immediate medical attention if symptoms worsen, fever develops, or she experiences vomiting that prevents oral medication 1.
- Urine culture should be obtained before starting antibiotics if possible to guide treatment 1.
From the Research
Presentation and Diagnosis
- The patient presents with nausea, back pain, and leukocytes in her urinalysis, which are symptoms suggestive of a urinary tract infection (UTI) 2.
- The diagnosis of acute pyelonephritis, a type of upper UTI, should be suspected based on the history and clinical examination, and can be confirmed with a urine culture 2.
- A negative urine dipstick for nitrites and leukocyte esterase does not exclude the diagnosis of UTI, and a re-evaluation of clinical features and consideration of other potential diagnoses should be performed 2.
Treatment
- Antibiotic therapy should be initiated without delay in patients with suspected UTI, and can be modified based on the culture result 2.
- First-line treatments for UTI include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are <20%) 3.
- Short-course antibiotic therapy, such as a 3-day course of ciprofloxacin, ofloxacin, or trimethoprim/sulfamethoxazole, can be effective for treating acute, uncomplicated lower UTI in women 4.
- The choice of antibiotic should take into account the risk of resistance and the patient's symptoms and characteristics 3.
Monitoring and Follow-up
- Patients with UTI should be monitored for improvement, and those who have not improved within two days of commencing antimicrobial treatment should be referred to secondary care 2.
- Urine culture is the gold standard for detection of UTI, and can help guide treatment and monitor for resistance 3.
- Follow-up evaluation at 4 to 6 weeks can help assess for recurrence of UTI 4.