Management of Dysuria in the Emergency Department
Immediate empirical antibiotic therapy is recommended for patients presenting to the ED with dysuria, as withholding antibiotics in patients with cystitis is not advised due to increased risk of symptom burden and progression to pyelonephritis. 1
Diagnostic Approach
- Obtain urine culture before initiating antibiotics to guide targeted therapy 2
- Urinalysis should be performed for most patients presenting with dysuria to help determine the presence of infection 3, 4
- Consider additional testing for sexually transmitted infections if vaginal discharge is present, as this decreases the likelihood of urinary tract infection 4
Treatment Algorithm
First-Line Treatment
- Start empirical broad-spectrum antibiotic therapy immediately after obtaining cultures for patients with signs of infection 1, 2
- For uncomplicated cystitis in women:
- Trimethoprim-sulfamethoxazole (TMP-SMX) is effective for susceptible strains of E. coli, Klebsiella, Enterobacter, and Proteus species 5
- Single-dose therapy with two double-strength TMP-SMX tablets (320 mg TMP/1600 mg SMZ) may be effective with fewer side effects than conventional therapy 6
- Nitrofurantoin is an alternative option, especially in areas with high TMP-SMX resistance 7
For Complicated UTIs or Systemic Symptoms
- Use broader coverage with third-generation cephalosporins such as ceftriaxone 1-2g daily 2
- Consider adding an aminoglycoside in severely ill patients 8
- For patients with sepsis or septic shock, start antibiotics immediately and use broader coverage including fourth-generation cephalosporins or carbapenems 1, 8
Treatment Duration
- Short-course antibiotic therapy (3-5 days) is recommended for uncomplicated cases with adequate source control 1
- For complicated UTIs, 7-14 days of treatment may be necessary 2
- Adjust antibiotic dose and timing based on patient's weight, renal clearance, and liver function 1
Special Considerations
- If a urinary catheter is present, remove it immediately as it represents the source of infection 8
- De-escalate antibiotics once culture and susceptibility results are available (typically within 48-72 hours) 8
- Empirical antifungal therapy is not recommended for urinary tract infections unless fungal infection is documented 1
- For patients with recurrent symptoms after initial treatment, further workup for both infectious and noninfectious causes is required 4
Common Pitfalls to Avoid
- Failing to obtain urine culture before starting antibiotics 2
- Using fluoroquinolones empirically when local resistance rates are high 2, 7
- Inadequate treatment duration, especially in complicated infections 2
- Evaluation and treatment through virtual encounters without laboratory testing may increase recurrent symptoms and antibiotic courses 4
- Equating all cases of dysuria to urinary infection is incorrect; consider non-infectious causes such as inflammation, trauma, neoplasm, calculi, hypoestrogenism, interstitial cystitis, or psychogenic disorders 3, 9