What medication can be given to a patient with dysuria suspected to be due to a urinary tract infection (UTI)?

Treatment for Dysuria in Suspected Urinary Tract Infection

First-line treatment options for a patient with dysuria suspected to be due to a urinary tract infection (UTI) include nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin. 1

Diagnosis Confirmation

• Send urine microscopy, culture, and sensitivity (M/C/S) before initiating treatment
• UTI diagnosis can be based on:
  • New onset dysuria, urinary frequency, urgency, nocturia, suprapubic discomfort
  • Urinalysis showing moderate to large leukocytes and positive nitrites
  • Bacterial counts >10,000 CFU/mL of a uropathogen

First-Line Treatment Options

1. Nitrofurantoin

• Dosing: 100 mg twice daily
• Duration: 5 days
• Advantages: Excellent coverage for most uropathogens, low resistance rates
• Contraindications: CrCl <30 mL/min, G6PD deficiency

2. Trimethoprim-Sulfamethoxazole (TMP-SMX)

• Dosing: One double-strength tablet (160 mg/800 mg) twice daily
• Duration: 3-5 days
• Advantages: Effective against most common uropathogens
• Caution: Areas with >20% resistance rates should avoid empiric use

3. Fosfomycin

• Dosing: 3 g single dose
• Advantages: Convenient single-dose regimen, good coverage
• Disadvantages: Higher cost, slightly lower efficacy than multiple-day regimens

Second-Line Treatment Options

1. Cephalexin

• Dosing: 500 mg four times daily
• Duration: 7 days
• Particularly useful when first-line options are contraindicated

2. Amoxicillin-Clavulanate

• Dosing: 500/125 mg three times daily
• Duration: 7 days
• For patients with impaired renal function (GFR 10-30 mL/min): 500/125 mg or 250/125 mg every 12 hours 2
• For severe renal impairment (GFR <10 mL/min): 500/125 mg or 250/125 mg every 24 hours 2

3. Ciprofloxacin (reserve option)

• Dosing: 250-500 mg twice daily
• Duration: 3 days for uncomplicated UTI
• Should be reserved for pyelonephritis or when first-line agents cannot be used 1, 3
• Renal dosing adjustments required for CrCl <50 mL/min 3

Special Considerations

Renal Impairment

• Adjust dosing based on creatinine clearance
• For ciprofloxacin:
  • CrCl 30-50 mL/min: 250-500 mg every 12 hours
  • CrCl 5-29 mL/min: 250-500 mg every 18 hours
  • Hemodialysis/peritoneal dialysis: 250-500 mg every 24 hours (after dialysis) 3

Recurrent UTIs

• Consider prophylactic antibiotics if frequent recurrences
• Options include TMP-SMX, nitrofurantoin, cephalexin, or fosfomycin 1
• Non-antibiotic measures:
  • Increased fluid intake
  • Voiding after sexual intercourse
  • Avoiding prolonged urine retention
  • Vaginal estrogen in postmenopausal women 1

Common Pitfalls to Avoid

1. Treating asymptomatic bacteriuria (not recommended in most populations)
2. Using fluoroquinolones as first-line therapy (should be reserved for more severe cases)
3. Not adjusting dosing for renal impairment
4. Unnecessary post-treatment urinalysis or cultures in asymptomatic patients
5. Overuse of broad-spectrum antibiotics for uncomplicated UTIs

Treatment Algorithm

1. Confirm diagnosis with appropriate symptoms and urinalysis
2. Select antibiotic based on patient factors:
   • For uncomplicated UTI in patients with normal renal function: nitrofurantoin, TMP-SMX, or fosfomycin
   • For patients with renal impairment: cephalexin or appropriately dosed alternatives
   • For complicated UTI or pyelonephritis: consider ciprofloxacin or broader coverage
3. Adjust treatment based on culture results when available
4. Evaluate for symptom resolution within 48-72 hours
5. Consider specialist referral for patients with medical comorbidities or recent travel to regions with high antibiotic resistance