From the Guidelines
This patient should be treated with a 3-day course of nitrofurantoin 100 mg twice daily, trimethoprim-sulfamethoxazole (TMP-SMX) double strength twice daily, or fosfomycin 3 g single dose for her current acute cystitis, and preventive strategies such as vaginal estrogen therapy should be implemented to address the underlying cause of her recurrent UTIs. The patient's history of recurrent UTIs, defined as at least three episodes of infection within the preceding 12 months 1, suggests that she may benefit from preventive measures. Vaginal estrogen therapy, such as estradiol vaginal cream or an estradiol vaginal ring, is a recommended treatment for postmenopausal women with recurrent UTIs, as it helps to improve vaginal and urethral tissue integrity and reduce the risk of infection 1.
Other preventive measures that may be beneficial for this patient include:
- Adequate hydration to promote more frequent urination
- Urinating after intercourse
- Wiping front to back
- Avoiding irritating feminine products
- Considering antibiotic prophylaxis, such as postcoital TMP-SMX single strength or nitrofurantoin 50-100 mg, or continuous low-dose prophylaxis for 3-6 months, if UTIs continue despite these measures 1.
It is also important to note that the patient's postmenopausal status and history of recurrent UTIs put her at increased risk for complications, and regular follow-up is important to monitor response to treatment and adjust the management plan as needed. The use of vaginal estrogen therapy is supported by strong evidence, and it is recommended by the European Association of Urology guidelines on urological infections 1.
In terms of diagnostic evaluation, a urine culture is recommended to diagnose recurrent UTI, but an extensive routine workup, such as cystoscopy or full abdominal ultrasound, is not necessary in women without risk factors 1. The patient's symptoms and history suggest that she has an uncomplicated UTI, and imaging studies are not indicated unless there are signs of complications or underlying anatomical abnormalities 1.
Overall, the patient's treatment plan should prioritize preventive strategies, such as vaginal estrogen therapy, and empiric antibiotic therapy for her current acute cystitis, with regular follow-up to monitor response to treatment and adjust the management plan as needed.
From the FDA Drug Label
Ciprofloxacin Tablets USP, 250 mg, 500 mg and 750 mg is indicated for the treatment of infections caused by susceptible strains of the designated microorganisms in the conditions and patient populations listed below. Adult Patients: Urinary Tract Infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, Providencia rettgeri, Morganella morganii, Citrobacter diversus, Citrobacter freundii, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus epidermidis, Staphylococcus saprophyticus, or Enterococcus faecalis Acute Uncomplicated Cystitis in females caused by Escherichia coli or Staphylococcus saprophyticus.
The patient's symptoms of increased urinary frequency and painful urination, along with a positive urinalysis for leukocyte esterase and nitrites, are consistent with acute uncomplicated cystitis. The FDA drug label for ciprofloxacin indicates that it is effective for the treatment of Acute Uncomplicated Cystitis in females caused by Escherichia coli or Staphylococcus saprophyticus 2. Therefore, ciprofloxacin is an appropriate treatment option for this patient. Key points:
- The patient's symptoms are consistent with acute uncomplicated cystitis
- Ciprofloxacin is indicated for the treatment of acute uncomplicated cystitis in females
- The patient's infection is likely caused by Escherichia coli or Staphylococcus saprophyticus, which are susceptible to ciprofloxacin.
From the Research
Patient Presentation and Diagnosis
- The patient is a 58-year-old woman with symptoms of increased urinary frequency and painful urination, which have not improved despite increasing fluid intake and voiding regularly.
- She has a history of two other episodes of acute simple cystitis in the past 8 months, which resolved with antibiotics.
- Physical examination shows mild suprapubic tenderness and no costovertebral tenderness, with thin vulvar tissue but no excoriations or lesions.
- Urinalysis is positive for leukocyte esterase and nitrites, indicating a urinary tract infection (UTI).
Treatment Options for UTIs
- According to 3, the recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females is a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam.
- 4 discusses the pharmacokinetic characteristics of oral antimicrobial agents for the treatment of uncomplicated UTIs and the importance of choosing an agent that optimizes clinical benefit and minimizes the risk of antibacterial resistance.
- 5 found that a 5-day course of nitrofurantoin is equivalent clinically and microbiologically to a 3-day course of trimethoprim-sulfamethoxazole for the treatment of acute cystitis in women.
Efficacy of Nitrofurantoin
- 6 compared the effectiveness of 5 versus 7 days of nitrofurantoin treatment for UTI in women with diabetes and found no clinically significant difference in treatment failure within 28 days.
- 7 found that nitrofurantoin retains antimicrobial activity against multidrug-resistant urinary Escherichia coli from US outpatients, with resistance to nitrofurantoin observed in only 2.1% of isolates that demonstrated resistance to three antimicrobial agents.
Considerations for Treatment
- The patient's symptoms and urinalysis results indicate a UTI, and the use of nitrofurantoin as a first-line treatment option is supported by the evidence.
- The patient's history of previous UTIs and her postmenopausal status may increase her risk of recurrent UTIs, and consideration of preventive measures may be necessary.