What is the treatment for a patient with a urinary tract infection (UTI) caused by Escherichia coli (E. coli) with symptoms and lab results indicating bacteriuria, hematuria, and proteinuria?

Treatment for E. coli Urinary Tract Infection with Hematuria and Proteinuria

Trimethoprim/sulfamethoxazole is the recommended first-line treatment for this uncomplicated urinary tract infection caused by E. coli, which is susceptible to this antibiotic as shown in the culture results. 1

Diagnosis Assessment

The urinalysis and culture results clearly indicate an active urinary tract infection:

• Positive nitrites and leukocyte esterase (trace)
• Elevated WBCs (10-20/HPF)
• Significant hematuria (≥60 RBCs/HPF)
• Proteinuria (2+)
• Culture growing >100,000 CFU/mL of E. coli

The presence of both pyuria and bacteriuria confirms this is a true UTI rather than asymptomatic bacteriuria, which would show bacteriuria without significant pyuria 2.

Treatment Recommendations

First-line Treatment

• Trimethoprim/sulfamethoxazole (TMP-SMX): The culture shows the E. coli is susceptible to this antibiotic, and it's FDA-approved for urinary tract infections caused by E. coli 1.
  • Dosage: One double-strength tablet (160 mg/800 mg) twice daily for 3 days for uncomplicated UTI
  • This regimen provides excellent coverage for the isolated pathogen while minimizing antibiotic exposure

Alternative Options (if allergies or contraindications to TMP-SMX exist):

1. Nitrofurantoin: Culture shows susceptibility and it's effective for lower UTI

   • Dosage: 100 mg twice daily for 5 days

2. Ciprofloxacin or Levofloxacin: Culture shows susceptibility 3

   • Ciprofloxacin: 250 mg twice daily for 3 days
   • Levofloxacin: 250 mg once daily for 3 days
   • Note: Fluoroquinolones should be reserved for cases where other options cannot be used due to their side effect profile and concerns about resistance 2

Treatment Duration

For an uncomplicated UTI in an adult:

• 3-day course for TMP-SMX or fluoroquinolones
• 5-day course for nitrofurantoin

If there are signs of complicated infection (fever, flank pain, or other systemic symptoms), extend treatment to 7-14 days 2.

Follow-up Recommendations

• No follow-up urine culture is necessary if symptoms resolve completely 2
• If symptoms persist beyond 48-72 hours of appropriate therapy, obtain a repeat urine culture
• If symptoms recur within 2 weeks after completing therapy, perform a urine culture with susceptibility testing, as the infecting organism may not have been susceptible to the initial treatment 2

Important Considerations

• Hydration: Encourage increased fluid intake to help flush bacteria from the urinary tract
• Symptom relief: Consider phenazopyridine for urinary pain/burning if needed (short-term use only)
• Warning signs: Advise the patient to seek immediate medical attention if fever, flank pain, nausea/vomiting develop, as these may indicate progression to pyelonephritis

Special Considerations

• The significant hematuria (≥60 RBCs/HPF) and proteinuria (2+) may indicate more severe inflammation or possibly underlying urological abnormalities
• If this is a recurrent UTI (≥3 episodes/year), consider urological evaluation after resolution of the acute infection 2
• The high bacterial count (>100,000 CFU/mL) confirms a true infection rather than contamination 2

Remember that proper antibiotic selection based on susceptibility testing is crucial for effective treatment and preventing antimicrobial resistance. The culture results show multiple effective options, with TMP-SMX being an appropriate first-line choice for this uncomplicated E. coli UTI.