What is the cause of persistent dysuria in a 74-year-old female, 2 days after completing antibiotic treatment, with a urinalysis positive for leukocytes (white blood cells)?

From the Guidelines

This 74-year-old female likely has a persistent urinary tract infection (UTI) despite recent antibiotic treatment and should be evaluated for a different antibiotic regimen, such as a 7-day course of nitrofurantoin, trimethoprim-sulfamethoxazole, or ciprofloxacin, as suggested by the European Association of Urology guidelines 1.

Key Considerations

• The patient's recent completion of antibiotic treatment 2 days ago and ongoing discomfort upon urination, along with positive leukocytes on urinalysis, indicate the need for a re-evaluation of the treatment approach.
• Elderly women, particularly those with comorbidities or frailty, are at a higher risk for complicated UTIs, which may require longer treatment durations or different antibiotic regimens 1.
• A urine culture should be collected before starting new antibiotics to guide the selection of the most appropriate antibiotic based on the bacteria's antibiotic sensitivities.

Treatment Approach

• The choice of antibiotic should consider the patient's specific condition, potential resistance patterns, and the latest guidelines from reputable sources such as the European Association of Urology 1.
• Increasing fluid intake and urinating frequently can help alleviate symptoms and support the recovery process.
• Close monitoring for worsening symptoms such as fever, flank pain, or nausea is crucial, as these could indicate the spread of the infection to the kidneys, requiring immediate medical attention.

Evidence-Based Decision

• The decision to change the antibiotic regimen is based on the most recent and highest quality evidence available, prioritizing the patient's morbidity, mortality, and quality of life outcomes 1.
• The European Urology guidelines from 2024 provide a comprehensive approach to managing urinary infections, including the diagnosis, treatment, and prevention of complications in older adults 1.

From the Research

Patient's Condition

The patient, a 74-year-old female, has recently completed antibiotic treatment 2 days ago and is still experiencing discomfort upon urination. Her urinalysis is positive for leukocytes, indicating a possible urinary tract infection (UTI) that may not have been fully resolved by the antibiotic treatment.

Possible Causes of Persistent Leukocytes

• The presence of leukocytes in the urinalysis could indicate that the UTI is not fully resolved, despite the completion of antibiotic treatment 2, 3, 4.
• Another possibility is that the patient has developed a new infection or has an underlying condition that is causing the leukocytosis, such as a persistent inflammation-immunosuppression and catabolism syndrome (PICS) 5.
• Hyperleukocytosis, which is defined as a white blood cell count greater than 100,000/mL, can also occur in patients with acute leukemia and is often associated with increased morbidity and mortality 6.

Treatment Options

• Nitrofurantoin is a commonly used antibiotic for treating uncomplicated UTIs and has been shown to be effective against E. coli, a common cause of UTIs 3, 4.
• Trimethoprim-sulfamethoxazole is another antibiotic that is often used to treat UTIs, but it may not be as effective as nitrofurantoin in some cases 2, 3.
• The choice of antibiotic should be based on the pharmacokinetic characteristics of the molecule and the susceptibility of the causative organism 4.

Next Steps

• Further evaluation and testing may be necessary to determine the cause of the patient's persistent leukocytes and to guide further treatment.
• The patient's symptoms and urinalysis results should be closely monitored to determine if the UTI is resolving or if further treatment is needed.