Student with Dysuria

Student with Dysuria

 PATIENT HISTORY

A 20-year-old college student complained of burning when urinating and a strong desire to void frequently although she had little urine to void. She was not experiencing any pelvic pain or discharge. Her symptoms beganshortly after she returned from a weekend visit to her boyfriend’s school.

She went to her university health service for diagnosis and treatment. On exam she was without fever and had moderate suprapubic tenderness, but

no flank tenderness.

LABORATORY TESTS

Urine Dipstick

A urine specimen was collected from this patient by a noninvasive technique,a midstream clean catch. Screening tests can predict which urine specimens contain a high colony count of bacteria. The most frequently used screening test with urine is called a “dipstick test”. A dipstick consists of plastic strips that contain multiple pads with chemical indicators. Normal urine is sterile, without protein, white cells, blood, or nitrites. A positive test for nitrites indicates the presence of bacteria that produce nitrate reductase, changing nitrate to nitrite. A positive test for leukocyte esterase indicates the presence of polymorphonuclear neutrophils (PMNs) in the urine that produce the enzyme. Inflammatory cells are the host’s response to infection. The strip is dipped into the urine, and the indicator

pads turn colors that are read immediately and compared to a scale of +1 to +4 . A dipstick test performed at the university health center on the urine from our college student showed positive reactions for both nitrate and leukocyte esterase, so her urine was sent to the lab for culture. A urine culture should be performed in patients with suspected cystitis regardless of dipstick results.

 TREATMENT AND PREVENTION

Factors to consider when treating UTI include:

■ Patient’s age and sex

■ Symptomatic versus asymptomatic infection

■ Upper (pyelonephritis) versus lower (cystitis) urinary tract involvement

■ Community- versus hospital-acquired infection

■ Single event versus recurrent events

■ Patient’s underlying illness

For uncomplicated cystitis a 3-day course of treatment is recommended. Symptoms usually resolve over 1–3 days. Many antibiotics with a broad range of activity against gram-negative rods and/or gram-positive cocci are suitable for the treatment of UTI, whether they are bacteriostatic or bacteriocidal drugs because they are concentrated 10–30-fold in the urine. Choices for initial empiric treatment of uncomplicated UTI in women include trimethoprim–sulfamethoxazole, a fluoroquinolone, or nitrofurantoin. The choice of an empiric antibiotic should always be based on the local prevalence of resistance in one’s geographic area, and this should be

periodically reevaluated. Ampicillin, amoxicillin, and sulfonamides are no longer considered good empiric choices because of the higher resistance rates seen in Enterobacteriaceae and Enterococcus spp. isolated from adults. Follow-up urine cultures are not necessary for patients with uncomplicated cystitis who respond clinically to treatment. Pregnant women should receive a follow-up culture 1–2 weeks after treatment. Complicated UTIs are more often caused by bacteria that may be resistant to the antibiotics used to treat uncomplicated UTI, particularly in hospitalized patients. Until the results of urine cultures are available in these patients, a fluoroquinolone is an excellent antibiotic choice in adult patients. In

these patients, treatment should be continued for 7–14 days. If symptoms resolve, a follow-up urine culture is not generally recommended.