How would you manage a patient with dysuria and frequency, suspected to have an uncomplicated urinary tract infection (UTI)?

Management of Uncomplicated UTI (Honeymoon Cystitis)

The correct answer is B. Nitrofurantoin - this patient should be treated with nitrofurantoin 100 mg twice daily for 5-7 days as first-line therapy for uncomplicated urinary tract infection. 1, 2

Clinical Context

This is a classic presentation of "honeymoon cystitis" - an uncomplicated lower UTI in an otherwise healthy young woman with acute-onset dysuria and frequency following recent sexual activity. 1 Dysuria is the central diagnostic symptom with >90% accuracy for UTI in young women when vaginal irritation or discharge is absent. 1

First-Line Antibiotic Selection

Nitrofurantoin is the preferred first-line agent based on current AUA/CUA/SUFU guidelines, which recommend three first-line options: nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin. 1, 2 The choice should be guided by local antibiogram data. 1

Why Nitrofurantoin is Superior:

• Maintains 95-96% susceptibility against E. coli uropathogens with only 2.3% resistance rates, even after 60+ years of use 3, 4
• Minimal collateral damage to normal vaginal and fecal flora compared to fluoroquinolones and cephalosporins 1
• Fluoroquinolone-sparing strategy is critical given ciprofloxacin resistance rates of approximately 24% 4
• Antimicrobial stewardship principles favor agents with lowest resistance impact 1

Dosing and Duration:

• Nitrofurantoin 100 mg twice daily for 5-7 days 2
• Treatment should be "as short as reasonable, generally no longer than 7 days" to balance symptom resolution with reducing resistance risk 1, 2

Why Other Options Are Incorrect:

A. Ampicillin - Not recommended as first-line therapy; not included in current guideline recommendations for uncomplicated UTI 1, 2

C. Ciprofloxacin - Should be avoided as first-line therapy due to increasing resistance rates (24% for E. coli), greater collateral damage to normal flora, and antimicrobial stewardship concerns 2, 5, 4 Fluoroquinolones are relegated to second-line status when first-line agents cannot be used 1

D. Ceftriaxone - Parenteral therapy is unnecessary for uncomplicated UTI and should be reserved for culture-resistant cases or complicated infections 1 This represents inappropriate broad-spectrum use 1

Critical Management Points:

Ideally Obtain Urine Culture First:

• Urine culture and sensitivity should be obtained prior to treatment in patients with recurrent UTIs to guide appropriate antibiotic selection 2
• However, empiric therapy can be initiated while awaiting culture results 1
• Patient-initiated (self-start) treatment is acceptable in reliable patients who obtain specimens before starting therapy 1

Avoid Common Pitfalls:

• Do not classify this as "complicated UTI" - this leads to inappropriate broad-spectrum antibiotic use with prolonged durations 1 This patient has no structural/functional abnormalities, immunosuppression, or systemic signs (fever, flank pain) 1
• Do not treat asymptomatic bacteriuria if it occurs later - this increases antimicrobial resistance without benefit 1, 2
• Do not routinely perform cystoscopy or upper tract imaging in uncomplicated recurrent UTI 1

Alternative First-Line Options:

If nitrofurantoin is contraindicated (renal impairment, late pregnancy):

• TMP-SMX 160/800 mg twice daily for 3-7 days - only if local resistance <20% 2
• Fosfomycin 3g single dose 1, 2, 5

Prevention Counseling:

Since this is post-coital UTI, consider discussing:

• Post-coital voiding within 2 hours of sexual activity 2
• Low-dose post-coital antibiotic prophylaxis if infections recur with sexual activity 1
• Adequate hydration and avoiding spermicidal contraceptives 2