Practice antibiotic stewardship to preserve benefits

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Ms. O, aged 35 years, presents to the urgent care clinic on a Sunday evening with a history of urinary frequency, urgency and burning which began suddenly that morning.

She denies fever, chills, nausea, vomiting, genital lesions, vaginal discharge or pain in her abdomen or back. During your interview with her, the patient reports that she is in a monogamous relationship with her husband of 10 years and they have two children, aged 6 and 4 years, both of whom were delivered vaginally with no complications.

Her medical history is unremarkable; specifically, she has no history of diabetes, cancer, autoimmune disease, kidney disease, sexually transmitted diseases or recent infections (urinary tract or other). She reports that she has not taken antibiotics in more than three years and has had only two UTIs during her lifetime. The first occurred when she became sexually active in her 20s and the second when she went on a five-day horse pack trip eight years ago. Both UTIs responded to a short course of sulfamethoxazole/trimethoprim (SMX/TMP; Bactrim, Septra).

Ms. O indicates that she and her family had just completed a three-day biking tour on the Saturday afternoon before she presented. She notes that she rode a bicycle for 6 or more hours on each of the three days and wonders whether that may have contributed to her current symptoms.

Her last menstrual period began 2 weeks ago and was normal. Her husband had a vasectomy after the birth of their second child. The only medication Ms. O takes is vitamin D3 2,000 IU daily; she has no known medication allergies.

Ms. O denies any history of tobacco or illicit drug use. During a typical weekend, she consumes two to four glasses of wine. The patient describes her diet as “healthy” and consisting of fruits, vegetables, whole grain, dairy products and lean protein sources. Her exercise regimen includes cycling or running on most days of the week. She works as a school nurse so that she can have the summers off to be with her children.

During her initial evaluation, vital signs are temperature 98.4°F, pulse 68 beats per minute, BP 112/70 mm Hg.

Ms. O weighs 120 lb. and is 5 ft. 5 in tall. She is in no acute distress. Physical examination reveals moderate suprapubic tenderness with no costovertebral angle or abdominal tenderness. Perineal exam is deferred. Dipstick analysis of a clean catch urine specimen is positive for some leukocytes and a moderate amount of nitrites and negative for glucose, ketones, protein and blood.

You diagnose an acute uncomplicated UTI. Because of its benign presentation, you elect not to culture the patient's urine. Ordinarily, you would prescribe SMX/TMP but it's after 7 PM and the local pharmacies are closed, so you provide Ms. O with enough samples for a three-day course of ciprofloxacin (Cipro) 250 mg b.i.d. and advise her that she can purchase pyridium, a urinary analgesic, in the OTC pharmacy aisle at a local supermarket.

You also counsel her to increase her fluid intake and to contact the urgent care clinic or her primary care provider if her symptoms worsen or have not improved in 24 hours.

The next evening, Ms. O calls to say that her symptoms are no better but they are no worse. You advise her to come in for a repeat urinalysis. Results show a large number of leukocytes and microhematuria, so you send the specimen for culture and sensitivity (C&S).

You then advise Ms. O to “double up” on her ciprofloxacin, so that she is taking 500 mg b.i.d., and you prescribe enough for three more days to cover her until the C&S results are known.

Approximately 48 hours later, the culture results reveal multiple colonies of Escherichia coli that are resistant to ciprofloxacin and levofloxacin (Levaquin) but sensitive to all other antibiotics on the panel, including ampicillin, amoxicillin/clavulanate (Augmentin), ceftriaxone (Rocephin), cefuroxime (Ceftin), nitrofurantoin (Furadantin, Macrodantin, Macrobid) and SMP/TMX.

You call Ms. O and advise her to stop the ciprofloxacin and start a three-day course of double-strength SMX/TMP twice daily. The next day, an elated Ms. O calls to thank you and reports that her symptoms have completely resolved.

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