From the Guidelines
The next best step in management for this 27-year-old woman with symptoms of dysuria and urinary frequency is oral fosfomycin (option G). This patient is presenting with classic symptoms of uncomplicated urinary tract infection (UTI), including burning with urination, frequency, and suprapubic tenderness. According to the European Association of Urology guidelines on urological infections, published in 2024 1, uncomplicated cystitis is defined as acute, sporadic, or recurrent cystitis limited to nonpregnant women with no known relevant anatomic or functional abnormalities in the urinary tract and no comorbidities. Since she is trying to conceive, fosfomycin is an appropriate choice as it is pregnancy category B and can be administered as a single 3-gram dose, which improves compliance. Fosfomycin has good coverage against common urinary pathogens including E. coli, which is the most frequent cause of UTIs, as stated in the guidelines 1. While a urine culture could be considered, empiric treatment is reasonable given her classic presentation and lack of complicating factors such as fever, flank pain, or history of recurrent UTIs. Some key points to consider in the management of uncomplicated UTIs include:
- The choice of antimicrobial therapy should be guided by the spectrum and susceptibility patterns of the aetiological pathogens; efficacy for the particular indication in clinical studies; tolerability and adverse reactions; adverse ecological effects; and costs and/or availability 1.
- 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, and for those whose symptoms resolve but recur within 2 wk, a urine culture and antimicrobial susceptibility testing should be performed 1. Ciprofloxacin should be avoided in women who may become pregnant due to potential risks to fetal cartilage development. Amoxicillin-clavulanate is not a first-line agent for uncomplicated UTIs. Reassurance alone would be inappropriate given her symptoms, and invasive procedures like cystoscopy or bladder ultrasound are unnecessary for an uncomplicated presentation.
From the Research
Patient Presentation
The patient is a 27-year-old woman presenting with severe burning pain with urination and urinary frequency. She has no history of serious illness and is currently trying to conceive a child.
Clinical Findings
- Mild tenderness to palpation over the suprapubic region
- No costovertebral angle tenderness
- Normal temperature, pulse, and blood pressure
- Laboratory studies are not specified
Management Options
- The patient's symptoms suggest an uncomplicated urinary tract infection (UTI)
- The following management options are considered:
- Oral antibiotics
- Urine culture
- Reassurance and follow-up
Recommended Treatment
- According to the studies 2, 3, 4, 5, 6, the recommended first-line treatment for uncomplicated UTI in women is a 5-day course of nitrofurantoin or a single dose of fosfomycin
- The choice of antibiotic should be based on the patient's medical history, allergy status, and local resistance patterns
- In this case, since the patient is trying to conceive, it is essential to choose an antibiotic that is safe for use during pregnancy
Next Best Step
- The next best step in management would be to prescribe a course of oral antibiotics, such as nitrofurantoin or fosfomycin, and to obtain a urine culture to confirm the diagnosis and guide further treatment
- Options G (Oral Fosfomycin) is a suitable choice for the patient's condition, considering her symptoms and the need for a safe and effective treatment during pregnancy attempts.