Review Question - QID 102803

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Urinary Tract Infections Treatment Medical QID: 102803 (M2.RL.12.1)

QID 102803 (Type "102803" in App Search)

A 74-year-old woman presents to the emergency department for shortness of breath and bilateral lower extremity pitting edema. She has had exacerbations like this in the past and notes that she has not been taking her home heart medications as scheduled. Review of systems is negative for any other symptoms including GI, urinary, and musculoskeletal symptoms. Physical exam reveals bilateral pulmonary crackles, lower extremity pitting edema that extends to the hip, and no abdominal tenderness. Neurological exam is unremarkable and the patient is at her baseline mental status. She is subsequently started on BiPAP, given furosemide, and admitted to the hospital with rapid improvement in her symptoms. Routine admission workup includes urinalysis, which shows >100,000 cfu/mL of E. coli. She has no known drug allergies. Which of the following is the most appropriate treatment for this patient for this finding?

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Ceftriaxone

29%

40/137

Levofloxacin

15%

21/137

Nitrofurantoin

12/137

No treatment

37%

51/137

Trimethoprim-sulfamethoxazole

8/137

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This patient has asymptomatic bacteriuria given her negative urinary symptoms on review of symptoms and urinalysis demonstrating E. coli. Asymptomatic bacteriuria usually resolves spontaneously in elderly patients without antibiotic therapy.

Asymptomatic bacteriuria is defined as > 100,000 colony-forming units of bacteria without symptoms of a urinary tract infection (UTI). The following patients do not require treatment for asymptomatic bacteriuria:

- The elderly
- Diabetics
- Nonpregnant and premenopausal women
- Spinal cord injury patients
- Patients with chronic and indwelling urinary catheters

The following patients require treatment for asymptomatic bacteriuria:
- Pregnant (high risk of conversion to symptomatic urinary tract infection)
- Urologic intervention

It is important to ensure that the patient is truly asymptomatic. This includes no increased urinary frequency or burning upon urination; however, patients also need to have a normal neurologic exam. In elderly patients, a urinary tract infection can lead to confusion and delirium; however, they may not endorse symptoms of dysuria.

Incorrect Answers:
Answer 1: Ceftriaxone is an appropriate antibiotic in an elderly and altered patient with a UTI, or in a patient with pyelonephritis. Otherwise, oral agents can be used for simple UTI's.

Answer 2: Levofloxacin is a fluoroquinolone that can lead to delirium and tendon rupture among many other side-effects. For this reason, it is reserved for complicated UTI's or critically ill patients.

Answer 3: Nitrofurantoin is an oral agent that can be used for a simple UTI, such as in a young woman with dysuria.

Answer 5: Trimethoprim-sulfamethoxazole is another oral agent for a simple UTI that would be indicated in a patient who is symptomatic with a positive urinalysis.

Bullet Summary:
Asymptomatic bacteriuria does not require antibiotic treatment except in pregnant patients and patients with recent urologic procedures.

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