ED Case Challenge: After New Sexual Partner, Dysuria, Discharge in a 21-Year-Old

Melanie Malloy, MD, PhD; Richard H. Sinert, DO


August 11, 2022

The treatment for simple cystitis is 3-7 days of antibiotic therapy. Antibiotic susceptibility of Escherichia coli varies widely by region, and an understanding of local antibiotic resistance patterns is essential to choosing appropriate therapy.

First-line therapy for simple cystitis includes nitrofurantoin, trimethoprim/sulfamethoxazole, or fosfomycin. Nitrofurantoin should not be used if pyelonephritis is at all suspected owing to poor tissue penetration. Alternatively, fluoroquinolones can be used, although in some regions, resistance can be up to 75%.[4] In North America, resistance has been estimated at 23.5% in hospitalized patients.[5]

For outpatients, ampicillin has been found to have a resistance rate of nearly 30%.[6] Given that the most current treatment guidelines advise against treating with any agent that has greater than 20% resistance, ampicillin is not an effective first-line treatment for uncomplicated cystitis in many areas of the United States.

The patient in this case was discharged home without empirical treatment. The urine culture grew 105 colony-forming units of gram-negative bacilli, later identified as E coli, which is susceptible to nitrofurantoin. The GC/chlamydia culture was negative for both organisms.

The patient was contacted by telephone and informed of the diagnosis of UTI. A prescription was called into her pharmacy for a 5-day course of nitrofurantoin. Phenazopyridine was prescribed together with the antibiotic as a urinary analgesic for the dysuria. She was alerted to the orange color that this medication imparts to the urine.


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