Does a patient with a history of transurethral resection of the prostate (TURP) and bladder issues, presenting with acute urinary retention and hematuria, require antibiotics if urine analysis shows hematuria and is nitrite positive, but the patient is afebrile and experiences pain relief with a Foley catheter?

From the Guidelines

Yes, antibiotics are indicated for this patient with acute urinary retention, hematuria, and a positive nitrite test, despite the absence of fever and relief of pain after catheterization. The positive nitrite test suggests bacterial infection, likely a urinary tract infection (UTI) 1. For empiric treatment, consider ciprofloxacin 500 mg orally twice daily for 7 days or trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg (one double-strength tablet) twice daily for 7 days. Alternatively, nitrofurantoin 100 mg orally four times daily for 7 days can be used if no renal impairment exists. Collect a urine culture before starting antibiotics to guide therapy if the empiric choice proves ineffective. The patient's history of urologic procedures increases risk for complicated UTI, and the presence of a Foley catheter can promote bacterial colonization. Even without fever, treatment is warranted to prevent progression to systemic infection or complications like pyelonephritis, as suggested by the European Association of Urology guidelines on urological infections 1. Monitor for symptom improvement and consider urologic follow-up to address the underlying cause of retention and hematuria. It is also important to note that the patient's symptoms, such as hematuria and urinary retention, are indicative of a complicated UTI, which requires prompt treatment to prevent further complications 1. The choice of antibiotic should be based on local resistance patterns and the patient's specific factors, such as allergies and renal function, as recommended by the Infectious Diseases Society of America 1. In addition, the patient's recent history of transurethral resection of the prostate (TURP) and bladder issues increases the risk of complicated UTI, and therefore, requires careful consideration of antibiotic treatment and monitoring for potential complications 1.

Some key points to consider in the management of this patient include:

• The importance of collecting a urine culture before starting antibiotics to guide therapy
• The need to consider local resistance patterns and the patient's specific factors, such as allergies and renal function, when choosing an antibiotic
• The potential for complicated UTI in patients with a history of urologic procedures and the presence of a Foley catheter
• The importance of monitoring for symptom improvement and considering urologic follow-up to address the underlying cause of retention and hematuria.

Overall, the patient's presentation and history suggest a complicated UTI, which requires prompt treatment with antibiotics to prevent further complications.

From the Research

Patient Presentation and Urine Analysis

• The patient presents with acute urinary retention and hematuria, and has a history of transurethral resection of the prostate (TURP) and bladder issues.
• Urine analysis shows hematuria and is nitrite positive, but the patient is afebrile and experiences pain relief with a Foley catheter.

Antibiotic Therapy Considerations

• According to 2, urinary tract infections (UTIs) are common and can be caused by various pathogens, including Escherichia coli.
• The study 3 recommends nitrofurantoin, fosfomycin, or pivmecillinam as first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females.
• However, the patient's presentation is not typical of uncomplicated cystitis, and the presence of hematuria and nitrite positivity suggests a possible UTI.
• The study 4 found that nitrite-positive groups demonstrated higher resistance to certain antibiotics, but suggests that urine bacteriology should be ordered to guide antibiotic therapy.
• The study 5 recommends immediate antimicrobial therapy for acute cystitis, but notes that individualized assessment of risk factors for resistance and regimen tolerability is needed to choose the optimum empirical regimen.
• The study 6 found that a positive nitrite test or a negative nitrite test with a positive leucocyte-esterase test confirmed UTI, and recommends prudent use of antibiotics.

Decision on Antibiotic Therapy

• Based on the patient's presentation and urine analysis, antibiotic therapy may be considered, but the choice of antibiotic and duration of therapy should be guided by urine bacteriology and individualized assessment of risk factors for resistance.
• The patient's afebrile status and pain relief with a Foley catheter suggest that the infection may not be severe, but antibiotic therapy may still be necessary to prevent complications.
• Further evaluation and urine culture are necessary to determine the best course of treatment, as recommended by 4 and 5.