What is the appropriate management for a 65-year-old female with a history of Chronic Obstructive Pulmonary Disease (COPD), Gastroesophageal Reflux Disease (GERD), and colon cancer, presenting with abdominal pain, malodorous urine, and a urinalysis showing hematuria and proteinuria, after being diagnosed with recurrent colon cancer and possible cystitis on a Computed Tomography (CT) scan?

From the Guidelines

I recommend treating this 65-year-old female with suspected urinary tract infection with empiric antibiotics while awaiting culture results, specifically nitrofurantoin (Macrobid) 100mg twice daily for 5-7 days or trimethoprim-sulfamethoxazole (Bactrim DS) one tablet twice daily for 3 days if there are no contraindications, as suggested by the most recent guidelines 1. The patient's positive urinalysis for blood and protein, along with her symptoms of malodorous urine and generalized abdominal discomfort, support the diagnosis of a urinary tract infection. Given her history of recurrent colon cancer and bladder wall thickening on CT, it is crucial to distinguish between infectious cystitis and potential malignant involvement of the bladder. The empiric treatment addresses the immediate concern of possible UTI while the broader workup for her cancer recurrence continues. It is essential for the patient to complete the full course of antibiotics even if symptoms improve, increase fluid intake, and follow up if symptoms worsen or don't improve within 48-72 hours. Her upcoming surgical oncology appointment is crucial, and the culture results should be reviewed promptly to adjust therapy if needed, considering the potential for complications and the need for tailored treatment approaches as outlined in recent clinical guidelines 1. The choice of empiric antibiotics should be guided by local resistance patterns and the patient's specific clinical context, with consideration of the most recent recommendations for urinary tract infections 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to empiric selection of therapy Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris

The patient can be treated with trimethoprim-sulfamethoxazole (PO) for a urinary tract infection, as it is indicated for the treatment of urinary tract infections due to susceptible strains of certain organisms, and the patient's symptoms and test results suggest a possible urinary tract infection 2.

Key points:

• The patient has a history of malodorous urine and abdominal discomfort
• Urine test results show blood and protein in the urine
• The patient is being treated empirically with antibiotics
• Trimethoprim-sulfamethoxazole (PO) is a suitable option for treating urinary tract infections caused by susceptible bacteria.

From the Research

Patient Presentation

The patient is a 65-year-old female with a past medical history of COPD, GERD, and colon cancer. She has been experiencing abdominal pain and was recently diagnosed with recurring colon cancer. A CAT scan showed bladder wall thickening, possible cystitis. She reports a 1 to 2-month history of sporadic malodorous urine and generalized abdominal discomfort.

Diagnostic Approach

• The patient's symptoms, such as malodorous urine and abdominal discomfort, suggest a possible urinary tract infection (UTI) 3, 4.
• The presence of blood and protein in the urine sample supports this diagnosis 3.
• A urine culture was sent to confirm the diagnosis and guide antibiotic selection 3, 4.

Treatment Approach

• The patient was treated with empiric antibiotics, which is a reasonable approach given the suspected diagnosis of UTI 3, 4.
• First-line antibiotics for uncomplicated UTIs in women include nitrofurantoin, fosfomycin, trimethoprim, or trimethoprim/sulfamethoxazole 3.
• The choice of antibiotic should be guided by the urine culture and susceptibility results, as well as the patient's medical history and potential allergies 3, 5, 6.

Considerations

• The patient's age and comorbidities, including colon cancer, may affect the choice of antibiotic and treatment duration 3, 7.
• The presence of bladder wall thickening on the CAT scan suggests possible cystitis, which may require a longer treatment duration 4.
• The patient's history of colon cancer and potential immunocompromised state may increase the risk of complications, such as pyelonephritis or sepsis 7, 4.