What to do if a patient still has urinary urgency on the last day of antibiotics (abx)?

Management of Persistent Urinary Urgency on the Last Day of Antibiotics

If a patient still has urinary urgency on the last day of antibiotics for a urinary tract infection, clinicians should repeat a urine culture to guide further management rather than empirically extending antibiotic therapy. 1

Assessment of Persistent Symptoms

When evaluating a patient with persistent urinary urgency at the end of an antibiotic course, consider:

• The European Association of Urology (EAU) guidelines emphasize that symptom resolution is the primary indicator of successful treatment 1
• According to the American Urological Association (AUA) guidelines, clinical cure (symptom resolution) is typically expected within 3-7 days of initiating antimicrobial therapy 1
• Persistent symptoms beyond 7 days warrant further investigation

Recommended Approach

1. Obtain a urine culture before considering additional antibiotics

   • The AUA guidelines explicitly recommend repeating urine cultures when UTI symptoms persist following antimicrobial therapy 1
   • This helps distinguish between persistent infection and other causes of urgency

2. Wait for culture results before prescribing additional antibiotics

   • Although a second antibiotic can be given empirically, this should only be done after obtaining a urine sample for culture 1
   • This minimizes unnecessary treatment of patients with persistent symptoms who are culture-negative

3. Consider alternative causes of persistent urgency

   • Non-infectious causes of urgency may include:
     • Pelvic floor dysfunction
     • Interstitial cystitis/bladder pain syndrome
     • Vaginal atrophy in peri/post-menopausal women
     • Urethral irritation from recent infection

Special Considerations

For Peri/Post-menopausal Women

• Consider vaginal estrogen therapy to reduce the risk of future UTIs 1
• Vaginal estrogen has been shown to reduce UTI recurrence in this population
• This is a moderate recommendation with Grade B evidence level

For Patients with Rapid Recurrence

• Consider evaluation both on and off therapy to identify patients who warrant further urologic evaluation 1
• Repeated infection with the same organism may indicate structural abnormalities

Important Caveats

• Avoid test-of-cure cultures in asymptomatic patients

  • The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines advise against "test of cure" cultures in patients whose symptoms have resolved 2
  • Microbiological eradication is not necessary if symptoms have resolved

• Avoid unnecessary antibiotic extension

  • Prescribing additional antibiotics despite symptom resolution increases resistance risk without clinical benefit 2
  • The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines suggest against withholding antibiotics in patients with cystitis 1, but also caution against unnecessary extension

• Consider structural abnormalities in recurrent cases

  • The AUA guidelines note that repeated infection with bacteria associated with struvite stone formation (e.g., P. mirabilis) may prompt consideration of imaging to rule out calculus 1

By following this evidence-based approach, clinicians can appropriately manage persistent urinary urgency while minimizing unnecessary antibiotic use and identifying patients who need further evaluation.