Should I treat a patient with dysuria and frequency with antibiotics?

Treatment of Dysuria and Frequency

Patients with dysuria and frequency should be treated with antibiotics as these symptoms strongly suggest a urinary tract infection (UTI). 1, 2

Diagnostic Considerations

• Dysuria and frequency are classic symptoms of UTI and typically warrant antibiotic treatment, as these symptoms indicate bacterial infection of the urinary tract 2, 3
• A focused history of lower urinary tract symptoms (dysuria, frequency, and urgency) with absence of vaginal discharge has high diagnostic value for UTI 1
• In patients presenting with typical symptoms of uncomplicated cystitis, urine analysis (culture, dipstick) provides only minimal increase in diagnostic accuracy 1
• However, a urine culture should be obtained before starting antibiotics in patients with recurrent UTIs to guide appropriate therapy 1

First-Line Antibiotic Treatment

• For uncomplicated UTI with dysuria and frequency, use short-course therapy with one of these first-line agents 1:

  • Nitrofurantoin (first choice when possible due to low resistance rates) 1
  • Trimethoprim-sulfamethoxazole (if local resistance rates are <20%) 4
  • Fosfomycin (single dose) 1

• Avoid fluoroquinolones (e.g., ciprofloxacin) for uncomplicated UTIs due to:

  • FDA advisory warning about serious adverse effects 1
  • Increasing resistance rates 1, 2
  • Risk of collateral damage to gut microbiota 1

Duration of Treatment

• For uncomplicated cystitis in women: 3-5 days of treatment is typically sufficient 1
• For men or complicated UTIs: 7-14 days may be required 1
• Longer courses are not needed for patients with recurrent UTIs 1

Special Considerations

• Asymptomatic bacteriuria should NOT be treated with antibiotics, even in patients with recurrent UTIs 1
• For patients with persistent symptoms despite treatment, repeat urine culture to assess for ongoing bacteriuria before prescribing additional antibiotics 1
• Antibiotic resistance should be considered if symptoms persist; E. coli is the most common pathogen (62.1%) but may be resistant to initial therapy 2
• In some cases of mild to moderate symptoms, symptomatic treatment (e.g., ibuprofen) may be considered as an alternative to antibiotics, but this approach should be used cautiously and with close follow-up 1, 5

Antibiotic Stewardship Considerations

• Unchecked, rampant use of antibiotics contributes to increasing resistance rates 2, 3
• When treating recurrent UTIs, avoid classifying as "complicated" as this often leads to unnecessary use of broad-spectrum antibiotics 1
• Escherichia coli remains the most common causative organism, but resistance patterns vary by region 2, 6
• Consider local antibiograms when selecting empiric therapy 1, 3

Follow-up

• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1
• For women whose symptoms do not resolve by the end of treatment, or recur within 2 weeks, obtain a urine culture and antimicrobial susceptibility testing 1
• Retreatment with a 7-day regimen using a different agent should be considered if initial treatment fails 1