What is the management plan for a 76-year-old patient with urinary retention, leukocytosis, and neutrophilia?

Management of Urinary Retention with Leukocytosis in a 76-Year-Old Patient

The 76-year-old patient with urinary retention, leukocytosis (19.1), and neutrophilia (90%) should be treated for a urinary tract infection with urgent bladder decompression via catheterization and empiric antibiotic therapy, as these findings strongly suggest urosepsis. 1, 2

Initial Management

1. Immediate Bladder Decompression

   • Insert a urinary catheter to relieve the retention 3
   • Consider changing any existing catheter prior to obtaining urine specimens 1
   • Document residual urine volume

2. Diagnostic Workup

   • Obtain urine and blood cultures before starting antibiotics 1, 2
   • Request urinalysis with microscopic examination for WBCs 1
   • Order a Gram stain of uncentrifuged urine 1
   • Complete basic metabolic panel to assess renal function 2

Antibiotic Therapy

The patient's leukocytosis (WBC >14,000 cells/mm³) and neutrophilia (>90%) strongly indicate bacterial infection, with a high likelihood ratio for detecting documented bacterial infection 1. Given the patient's age and clinical presentation, initiate empiric antibiotic therapy immediately:

First-line options (pending culture results):

• Cefpodoxime 200 mg twice daily (adjust for renal function) 2
• OR Ciprofloxacin 500 mg every 12 hours (adjust for renal function) 2

Duration: 7-10 days for complicated UTI with urinary retention 2

Ongoing Management

1. Reassess in 48-72 hours:

   • Evaluate clinical response 2
   • Review culture results and adjust antibiotics accordingly
   • If symptoms persist or worsen, consider imaging to rule out obstruction or abscess

2. Address contributing factors:

   • Evaluate for underlying causes of urinary retention (prostatic hyperplasia, medications, neurological issues)
   • Correct dehydration if present 2
   • Review and discontinue unnecessary medications that may contribute to retention 2

3. Monitor for complications:

   • Assess for signs of sepsis (hypotension, altered mental status)
   • Monitor renal function, especially if using potentially nephrotoxic antibiotics 2
   • Ensure adequate urine output (aim for approximately 1L/24h) 2

Special Considerations

• Catheter management: Determine whether long-term catheterization is needed or if the patient can void spontaneously after treatment
• Antibiotic resistance: Consider local resistance patterns when selecting empiric therapy; E. coli resistance to fluoroquinolones can be as high as 25.2% 4
• Avoid treatment of asymptomatic bacteriuria: Once the acute infection resolves, avoid treating asymptomatic bacteriuria in older adults 1, 2

Pitfalls and Caveats

• Fever may be absent in elderly patients with serious infections; leukocytosis with left shift is a more reliable indicator 1
• Elderly patients with UTIs often present with atypical symptoms like confusion or altered mental status rather than classic urinary symptoms 2
• While obtaining cultures is important, do not delay antibiotic therapy in a patient with this degree of leukocytosis and neutrophilia 1
• Diabetes mellitus and urinary tract obstruction significantly increase the risk of urosepsis in patients with UTI 5