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Review Question - QID 103294

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QID 103294 (Type "103294" in App Search)
A 29-year-old G1P0 woman at 24 weeks gestation presents to her physician with complaints of burning with urination, and she reports that she has been urinating much more frequently than usual over the past several days. She otherwise is doing well and has experienced no complications with her pregnancy or vaginal discharge. Her temperature is 97.5°F (36.4°C), blood pressure is 112/82 mmHg, pulse is 89/min, respirations are 19/min, and oxygen saturation is 98% on room air. Examination is significant for suprapubic discomfort upon palpation and a gravid uterus. There is no costovertebral angle tenderness. Urinalysis shows increased leukocyte esterase, elevated nitrites, 55 leukocytes/hpf, and bacteria. The physician prescribes a 7-day course of nitrofurantoin. Which of the following is the next best step in management?

Add ciprofloxacin to antibiotic regimen

9%

2/22

Add penicillin to antibiotic regimen

5%

1/22

Perform a renal ultrasound

9%

2/22

Send a urine culture

45%

10/22

Test for gonorrhea and chlamydia

23%

5/22

Select Answer to see Preferred Response

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This pregnant patient is suffering from acute cystitis and is appropriately treated with nitrofurantoin. In pregnant patients, if urinalysis is found to be positive, urine culture should be sent in addition to initiating antibiotics.

Urine culture is necessary in order to assess the sensitivity of the infecting organism to the prescribed antibiotics. This allows for antibiotic therapy to be adjusted to the most effective agent. Due to the physiologic changes associated with pregnancy (including urinary retention, ureteral dilation, and increased urinary tract volume), pregnant patients are at an increased risk of acquiring and developing severe complications from urinary tract infections. In pregnant patients, pyelonephritis requires hospital admission and intravenous antibiotic treatment. However, asymptomatic bacteriuria and cystitis may be managed with oral antibiotic therapy. It is important to note that asymptomatic bacteriuria must be treated in a pregnant patient in contrast to other populations.

Incorrect Answers:
Answer 1: Add ciprofloxacin to antibiotic regimen is inappropriate as it can lead to tendon rupture and is contraindicated in pregnancy. It could be used to treat a complicated urinary tract infection; however, it is not a preferred initial agent in most patients.

Answer 2: Add penicillin to antibiotic regimen is unnecessary and is not appropriate for treating a UTI. There is widespread resistance to penicillin; therefore, addition of this medication would not be beneficial regardless.

Answer 3: Perform a renal ultrasound is the diagnostic test of choice in a pregnant patient with a kidney stone which would present with flank pain that radiates to the groin with hematuria. An ultrasound spares the pregnant mother from being exposed to radiation and may demonstrate hydronephrosis.

Answer 5: Test for gonorrhea and chlamydia would likely be performed at this patient's early prenatal appointments; however, there is no need to repeat testing in this patient merely because she is presenting with a UTI.

Bullet Summary:
Management of a UTI in pregnancy involves urinalysis, administration of antibiotics, and sending off a urine culture.

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