UTI Uncomplicated: Simple Acute Cystitis (FL INITIAL Autonomous Practice - Differential Diagnosis)

Simple acute cystitis among women is extremely common. Among otherwise healthy women, risk factors for simple acute cystitis include (Hooton & Gupta, 2021; Hooton & Calderwood, 2020):

• Sexual activity:
  • Recent sexual intercourse
    • Sexually active women tend to have more UTIs than do women who are not sexually active
  • Having a new sexual partner
• Certain types of birth control:
  • Use of spermicide-coated condoms, diaphragms, and spermicides
• Female anatomy:
  • A woman has a shorter urethra than a man, which shortens the distance that bacteria must travel to reach the bladder
  • Anatomically speaking, the shorter distance from the anus to the urethra likely explains why women are at higher risk for UTIs than men
• History of UTI’s
• Menopause:
  • After menopause, a decline in circulating estrogen causes changes in the urinary tract that increase infection risk

Simple acute cystitis occurs in a very small proportion of men between 15 and 50 years of age. The incidence is approximately five to eight UTIs per year per 10,000 young to middle-aged men. Among otherwise healthy men, risk factors associated with simple acute cystitis include (Hooton & Gupta, 2021; Hooton & Calderwood, 2020):

• Sexual activity:
  • Insertive anal intercourse
• Male anatomy:
  • Symptomatic UTI is much less common in men than in women due to:
    • Longer urethral length
    • Drier periurethral environment (with less frequent colonization around the urethra)
    • Antibacterial substances in prostatic fluid
  • Lack of circumcision
• History of UTI’s

Other comorbidities in both men and women which increase the risk factors for simple acute cystitis include (Hooton & Gupta, 2021; Hooton & Calderwood, 2020):

• Urinary tract abnormalities:
  • Babies born with urinary tract abnormalities that do not allow urine to leave the body normally or cause urine to back up in the urethra have an increased risk of UTIs
• Blockages in the urinary tract such as kidney stones or an enlarged prostate can trap urine in the bladder
• A suppressed immune system such as diabetes mellitus, HIV/AIDS, etc
• Catheter use includes people who are hospitalized, people with neurological problems that make it difficult to control their ability to urinate, and people who are paralyzed (Fekete, 2021)
• A recent urinary procedure, i.e., urinary surgery or an examination of a person’s urinary tract that involves medical instruments

The microbial spectrum of simple acute cystitis in patients with recent antimicrobial or other health care exposures may be broader and also include other gram-negative bacilli such as (Hooton & Gupta, 2021):

• Enterococci
• Pseudomonas
• Staphylococci

Culture and susceptibility testing are essential for management in patients who have such risk factors. Resistance to E. coli can be a major issue.

Among otherwise healthy nonpregnant women, the isolation of organisms such as lactobacilli, enterococci, Group B streptococci, and coagulase-negative staphylococci other than S. saprophyticus from voided midstream urine most commonly represents contamination of the urine specimen. Nevertheless, it may be appropriate to consider these organisms the likely causative agent in symptomatic women when found in voided midstream urine at high counts and with pure growth (i.e., without growth of other bacteria).

Expected susceptibility patterns of E. coli should be the basis for the empiric antimicrobial selection for simple acute cystitis. Increasing rates of resistance have been reported globally.

Risk factors for UTI with resistant organisms include (Hooton & Gupta, 2021):

• Health care exposures during inpatient stay at a health care facility
• Recent broad-spectrum antimicrobial use
• Travel to parts of the world where multidrug-resistant organisms are prevalent:
  • Higher in medical centers in the US than in Canada
  • Higher in Portugal and Spain than in other European countries
• A multidrug-resistant gram-negative urinary isolate in the prior three months

When there are no clear risk factors for resistance, nitrofurantoin, fosfomycin, and pivmecillinam are appropriate first-line agents for simple acute cystitis. Resistance rates for first and second-generation oral cephalosporins and amoxicillin-clavulanic acid are regionally variable but generally <10%. Fluoroquinolone resistance rates have been <10% in most parts of North America and Europe, but there has been a clear trend of increasing resistance over time.

When interpreting these data, it is important to remember that passive laboratory-based surveillance methods tend to overestimate true resistance rates since they are skewed by urine cultures obtained from patients who may have failed initial therapy or who have specific risk factors for resistance, such as recent travel or antimicrobial use.

Trimethoprim-Sulfamethoxazole (TMP-SMX) is the agent for which there is the most data to guide clinical use. Identified risk factors for resistance in women with simple acute cystitis include (Hooton & Gupta, 2021):

• Travel, particularly international travel
• Use of TMP-SMX in the preceding three to six months

Studies have suggested that a 20% resistance prevalence should be the threshold at which TMP-SMX should not be used for empiric treatment of simple acute cystitis (Hooton & Gupta, 2021).

For other antimicrobial agents, there is insufficient data to determine the resistance levels at which the likelihood of failure outweighs the potential benefits. The decision to prescribe an appropriate antibiotic agent depends on the discretion of the individual practitioner. Additionally, practitioners need to understand that local resistance rates reported in hospital antibiograms are often skewed by cultures of samples obtained from hospitalized patients or those with complicated infections and may not accurately predict susceptibilities in women with simple acute community-acquired cystitis, in whom resistance rates tend to be lower (Hooton & Gupta, 2021).

The classic clinical manifestations of simple acute cystitis in both sexes include:

• Dysuria
• Hematuria
• Suprapubic pain
• Urinary frequency
• Urinary urgency

Fever, chills, rigors, and other signs of systemic illness raise the possibility of pyelonephritis or other complications of a UTI and, thus, are not compatible with a diagnosis of simple acute cystitis.

An important thing to note for women is the presence/absence of vaginal symptoms (e.g., vaginal pruritus or discharge). The probability of simple acute cystitis is greater than 50% in women with any of these symptoms and greater than 90% in women with dysuria and frequency without vaginal discharge or irritation. Hematuria is also often observed. Symptoms of simple acute cystitis can occasionally be subtle and more difficult to tease out, especially in older women (Hooton & Gupta, 2021; Hooten & Calderwood, 2020).

Older women can have several nonspecific urinary symptoms (such as chronic dysuria or urinary incontinence) that mimic symptoms of simple acute cystitis, even when there is no evidence of UTI. A systematic review of studies evaluating UTI diagnosis among community-dwelling adults older than 65 suggested that symptoms such as chronic urinary nocturia, incontinence, and a general sense of lack of well-being were common and nonspecific for UTI. Women should be asked about fevers/chills and flank pain.

Suppose fever (>99.9°F/37.7°C), other signs or symptoms of systemic illness (including chills, rigors, or marked fatigue or malaise beyond baseline), flank pain, or CVA tenderness are present. In this case, the patient should be evaluated and managed as potentially having a complicated UTI.

Acute dysuria (less than one-week duration), new or worsening urinary urgency, new incontinence, frequency, gross hematuria, and suprapubic pain or tenderness are considered discriminating symptoms. Fever is also a discriminating feature, although it is common to consider patients with cystitis symptoms and fever to have a complicated UTI. Among debilitated patients, many generalized signs or symptoms, e.g., falls, changes in functional status, and mental status, are not reliable predictors of bacteriuria or cystitis.

Although cloudy or smelly urine may be associated with bacteriuria, as demonstrated in nursing home residents, there is no evidence treating patients with only these complaints as having a UTI before the onset of usual cystitis symptoms is indicated. Color and odor of urine are influenced by ingestion of certain foods, dehydration, and other noninfectious factors. Consequently, increased fluid intake and careful observation are reasonable initial approaches to patients who complain of changes in odor or color of urine (Hooton & Gupta, 2021; Hooten & Calderwood, 2020).

Prostatitis should be considered in men presenting with cystitis symptoms that are recurrent or are accompanied by pelvic or perineal pain or fever.

Physical examination is often not essential for the diagnosis, but if performed, should include assessment for (Hooton & Gupta, 2021; Hooten & Calderwood, 2020):

• Abdominal tenderness
• Fever
• CVA tenderness
• Suprapubic tenderness

In addition, specifically for female patients, a pelvic examination is indicated if symptoms or signs suggesting vaginitis or urethritis are present. Among sexually active young women, a pelvic examination should be performed, particularly if symptoms are not convincing for a UTI, to evaluate for cervical motion or uterine tenderness, which would be suggestive of pelvic inflammatory disease (PID).

For male patients, urethritis must be considered in sexually active men. An examination should include assessing for penile ulcerations as well as urethral discharge. A digital rectal examination should be performed on men who present with pelvic or perineal pain or fever symptoms to evaluate for a tender or edematous prostate that would suggest acute prostatitis.

Suppose fever (>99.9°F/37.7°C), other signs or symptoms of systemic illness (including chills, rigors, or marked fatigue or malaise beyond baseline), flank pain, or CVA tenderness are present. In this case, these signs and symptoms are not compatible with a diagnosis of simple acute cystitis and raise the possibility of pyelonephritis, prostatitis, or other complications of a UTI. These patients should be evaluated and managed as potentially having a complicated UTI.

For most women with suspected simple acute cystitis, particularly those with classic symptoms, no additional testing is warranted to make the diagnosis.

If additional testing is warranted, the following diagnostics can be ordered (Hooton & Gupta, 2021; Hooten & Calderwood, 2020):

Additional diagnostics can include (Hooton & Gupta, 2021; Hooten & Calderwood, 2020):

• A midstream urine culture is recommended to confirm the diagnosis of UTI in men. In women in whom coliform bacteria (e.g., Escherichia coli) are isolated, lower colony counts are likely to represent infecting organisms. It is unknown if the same is true for men. The spectrum of isolates causing simple acute cystitis in men is not well defined but is likely similar to that in women.
• Urine Gram stain may help guide the choice of empiric therapy pending culture results.
• Pregnancy testing is appropriate in women of childbearing potential when the possibility of pregnancy cannot be reasonably excluded by history alone.
• Blood testing is not warranted for patients with simple acute cystitis.
• Laboratory tests for men should also include:
  • Evaluation of a urethral swab specimen Gram stain.
  • Diagnostic tests for Neisseria gonorrhoeae and Chlamydia trachomatis.
  • A urethral Gram stain demonstrating leukocytes and predominant gram-negative rods suggests E. coli urethritis, which may precede or accompany a UTI.

In women with simple acute cystitis, the causative organisms and their antimicrobial susceptibility profiles are frequently predictable. Consequently, routine cultures for such infections are often not necessary for management decisions. Given the increasing prevalence of antimicrobial resistance among uropathogens, obtaining a urine culture before initiation of therapy is warranted in patients who have risk factors for antimicrobial resistance, as well as in patients at risk for more serious infection (e.g., those with underlying urologic abnormalities, immunocompromising conditions, and poorly controlled diabetes mellitus).

Suppose voided urine cultures are sent to the laboratory. In this case, the practitioner should ask the laboratory to quantify E. coli, if it grows, to at least 10³ colony-forming units/mL to improve specificity. Moreover, E. coli should not necessarily be considered a contaminant if it grows in mixed flora since almost any growth of E. coli in voided urine in a symptomatic patient reflects bladder growth. Growth of organisms generally thought to be contaminants (lactobacilli, enterococci, Group B streptococci, and non-saprophyticus coagulase-negative staphylococci) may be considered causative when found in voided midstream urine at high counts and with pure growth.

• Dysuria, urinary frequency, and urgency, and pyuria can also be seen with acute bacterial prostatitis.
• The presence of fever, chills, malaise, myalgias, pelvic or perineal pain, or obstructive symptoms such as dribbling and hesitancy (due to acute urinary retention) in a man with symptoms of simple acute cystitis suggests acute bacterial prostatitis.
• Pain radiating to the tip of the penis has also been described in patients with acute prostatitis, but the sensitivity and specificity of this symptom has not been validated. Any of these signs and symptoms should prompt a gentle digital rectal examination and the finding of an edematous and tender prostate helps confirm this alternate diagnosis.

• Underlying chronic prostatitis should be considered in men with simple acute cystitis, particularly in those men who have recurrent UTIs caused by the same strain of bacteria.

• This is a diagnosis of exclusion in women who have ongoing discomfort related to the bladder with symptoms of dysuria, frequency, and urgency but no evidence of infection or other identifiable cause.

• Lower abdominal or pelvic pain and fever are the most common clinical findings in patients with PID, although dysuria may also be present.
• The findings of mucopurulent endocervical discharge or cervical motion tenderness on pelvic examination are strongly suggestive of PID.

• Evaluation for urethritis is warranted in sexually active men and women with dysuria, particularly those with pyuria on urinalysis but no bacteriuria.
• Causes of urethritis include:
  • Candida species
  • Chlamydia
  • Herpes simplex virus
  • Gonorrhea
  • Noninfectious irritants, such as a contraceptive gel
  • Trichomoniasis

• In women with dysuria, the presence of vaginal discharge or odor, pruritus, dyspareunia, and absence of urinary frequency or urgency should prompt consideration of vaginitis.
• Causes of vaginitis include:
  • Bacterial vaginosis (BV)
  • Trichomoniasis
  • Yeast infection

β-lactam antibiotics (beta-lactam antibiotics) are a class of broad-spectrum antibiotics consisting of all antibiotic agents that contain a beta-lactam ring in their molecular structures. Most β-lactam antibiotics work by inhibiting cell wall biosynthesis in the bacterial organism and are the most widely used group of antibiotics. Bacteria often develop resistance to β-lactam antibiotics by synthesizing a β-lactamase, an enzyme that attacks the β-lactam ring. To overcome this resistance, β-lactam antibiotics are often given with β-lactamase inhibitors such as clavulanic acid (Hooten & Gupta, 2021; Hooten & Calderwood, 2020).

Fluoroquinolones, which contain a fluorine atom in their chemical structure, are effective against Gram-negative and Gram-positive bacteria (Hooten & Gupta, 2021; Hooten & Calderwood, 2020).

• Ciprofloxacin
• Levofloxacin
• Moxifloxacin
• Norfloxacin
• Ofloxacin

Co-trimoxazole antibiotic is a combination of trimethoprim and sulfamethoxazole (TMP-SMX). It has a greater effect when given together than when given separately because they inhibit successive steps in the folate synthesis pathway. They are given in a one-to-five ratio in their tablet formulations. When they enter the body, their concentration in the blood and tissues is roughly one-to-twenty — the exact ratio required for a peak synergistic effect between the two (Hooten & Gupta, 2021; Hooten & Calderwood, 2020).

Fosfomycin is a novel class of antibacterial with a chemical structure unrelated to other known antibiotics. It is a bactericidal drug that disrupts cell wall synthesis by inhibiting phosphoenolpyruvate synthetase and thus interferes with the production of peptidoglycan (Hooten & Gupta, 2021; Hooten & Calderwood, 2020).

Nitrofurantoin monohydrate macrocrystal is bactericidal. The mechanism of action is unique and complex. The drug works by damaging bacterial DNA since its reduced form is highly reactive. Rapid reduction of nitrofurantoin inside the bacterial cell by flavoproteins (nitrofuran reductase) to multiple reactive intermediates that attack ribosomal proteins, DNA, pyruvate metabolism, and other macromolecules within the cell (Hooten & Gupta, 2021; Hooten & Calderwood, 2020).

No studies have evaluated the optimal duration of antimicrobial therapy in men with simple acute cystitis. Fluoroquinolones can be given for five days and other agents can be given for seven days. Fosfomycin is given as a single dose, but there is no experience with using this regimen in men with simple acute cystitis.

In men with simple acute cystitis who have no signs or symptoms suggestive of pyelonephritis or prostatitis (e.g., fever, flank pain, pelvic pain, prostatic tenderness on a digital rectal exam if this part of the examination is performed), a seven-day or shorter course of an antimicrobial to which the infecting strain is susceptible is likely to be sufficient (Hooten & Gupta, 2021; Hooten & Calderwood, 2020).

In a large retrospective study of 33,336 male veterans who received antimicrobial therapy for a UTI, as identified through billing codes (and not necessarily specified as simple or uncomplicated), there was no difference in the risk of early (less than 30 days after a prior UTI) or late (30 days or longer after a prior UTI) recurrence between those who received a short (seven days or less) or long (more than seven days) course of antimicrobials (Hooten & Gupta, 2021; Hooten & Calderwood, 2020). Moreover, in a multivariate analysis, there was a nonsignificant trend toward increased risk in the incidence of Clostridioides difficile infection among patients who received a longer course of therapy. In a subsequent database study of 573 men attending outpatient clinics, treatment for more than seven days was associated with a higher risk of recurrence when men with urologic abnormalities, immunocompromising conditions, prostatitis, pyelonephritis, nephrolithiasis, and benign prostatic hyperplasia were excluded from the analysis. Because of the inherent limitations in the interpretation of retrospective studies, prospective studies are warranted to elucidate further the benefits and harms of shorter- versus longer-duration treatment for UTIs in men (Hooten & Gupta, 2021; Hooten & Calderwood, 2020).

Patients are at higher risk for a Multi-Drug Resistant (MDR) gram-negative organism if they have any of the following occurring in the prior three months (Hooten & Gupta, 2021; Hooten & Calderwood, 2020):

• An MDR gram-negative urinary isolate (i.e., nonsusceptible to at least one agent in three or more antimicrobial classes), including ESBL-producing isolates.
• Inpatient stays in a health care facility (e.g., hospital, nursing home, long-term acute care facility).
• Use of a fluoroquinolone, TMP-SMX, or a broad-spectrum beta-lactam (e.g., third or later generation cephalosporin).
• Travel to parts of the world with high rates of MDR organisms (e.g., India, Israel, Spain, and Mexico).

One of the first-line antimicrobial regimens should be chosen for empiric therapy of simple acute cystitis in patients who do not have risk factors for an MDR gram-negative infection (Hooten & Gupta, 2021; Hooten & Calderwood, 2020):

• Nitrofurantoin monohydrate/macrocrystals (Macrobid®)
• TMP-SMX
• Fosfomycin
• Pivmecillinam

For patients who have reasons to avoid all these options (either because of allergies, intolerances, or a history of a urinary isolate resistant to these agents within the prior three months), an alternative option should be chosen (see below).

The preferred agents for empiric therapy of simple acute cystitis are nitrofurantoin monohydrate/macrocrystals, TMP-SMX, fosfomycin, and, if available, pivmecillinam because of the favorable balance between efficacy and adverse effects (including the risk of selecting for resistant organisms). None of the first-line agents outweigh the others in the efficacy/adverse effects balance, except that resistance is more likely with TMP-SMX and that pivmecillinam (and possibly fosfomycin) is somewhat less effective.

The optimal antimicrobial in one region may be different from that in another depending on resistance prevalence. As such, the choice among them should be individualized based on patient circumstances (allergy, tolerability, and expected adherence), local community resistance prevalence, availability, cost, and patient and provider threshold for failure. If the patient has taken one of the agents in the preceding three months, a different one should be selected.

If all of these are appropriate based on patient circumstances and prior urinary isolates, nitrofurantoin or TMP-SMX is suggested rather than Fosfomycin or pivmecillinam. Fosfomycin is usually reserved for suspected MDR infections or when other first-line agents cannot be used. It retains activity against many MDR isolates and overuse may increase resistance rates. Pivmecillinam is somewhat less effective but is commonly used in Europe because of its low risk for resistance.

The following information provides details on dosing, expected efficacy, and additional reasons for avoidance of first-line antimicrobials (Hooten & Gupta, 2021; Hooten & Calderwood, 2020):

If any factors (such as allergies or intolerances or concern for resistance) preclude using the above first-line antimicrobials, oral beta-lactams are appropriate options. Acceptable beta-lactam agents include (Hooten & Gupta, 2021; Hooten & Calderwood, 2020):

• Amoxicillin-clavulanate:
  • 500 mg orally twice daily for five to seven days
• Cefadroxil:
  • 500 mg orally twice daily for five to seven days
• Cefdinir:
  • 300 mg orally twice daily for five to seven days
• Cefpodoxime:
  • 100 mg orally twice daily for five to seven days
• Cephalexin:
  • 250 to 500 mg every six hours
  • Less well studied but may be acceptable

Ampicillin or amoxicillin should not be used for empiric treatment, given the high prevalence of resistance to these agents. Suppose an Enterococcus or Group B Streptococcus grows as the only isolate on culture and is determined to cause simple acute cystitis. In that case, amoxicillin is usually the preferred agent, as long as the isolate is susceptible. In general, beta-lactams are second-line agents because they are less effective and have more potential adverse effects than other UTI antimicrobials. If beta-lactams cannot be used because of severe allergy, appropriate alternative fluoroquinolone antibiotics include (Hooten & Gupta, 2021; Hooten & Calderwood, 2020):

• Ciprofloxacin:
  • 250 mg orally twice daily for three days or 500 mg extended-release orally daily for three days
• Levofloxacin:
  • 250 mg orally daily for three days
• Other less commonly used fluoroquinolones that are effective include:
  • Ofloxacin
  • Norfloxacin
  • Moxifloxacin attains lower urinary levels than other fluoroquinolones and should not be used

Multiple randomized trials have demonstrated that fluoroquinolones are very effective for treating simple acute cystitis and that fluoroquinolones are more effective than beta-lactams. However, increasing rates of resistance mitigate the utility of the fluoroquinolone class. Furthermore, because of concerns about the adverse effects of fluoroquinolones, the risk-benefit balance for simple acute cystitis favors the use of fluoroquinolones only if other agents (including beta-lactams) cannot be used. When possible, fluoroquinolones should be reserved for more serious infections than simple acute cystitis. If a fluoroquinolone is used, patients should be advised about the uncommon but potentially serious musculoskeletal and neurologic adverse effects.

Suppose a patient has reasons not to use any of the first-line agents, beta-lactams, or fluoroquinolones. In that case, a urine culture and susceptibility test should be performed and an antimicrobial agent should be chosen based on those results. Studies among women without comorbidities have suggested that deferring antimicrobial therapy until these results are available is a safe strategy for simple acute cystitis.

If there are concerns about deferring antimicrobials (e.g., because of significant bladder symptoms), it is reasonable to treat empirically with an agent (e.g., first-line option, beta-lactam, or fluoroquinolone) that was initially avoided because of concerns for possible resistance while awaiting culture results. Alternately, if there are concerns about potential treatment failure with oral agents in patients with risk factors for more serious infection (e.g., an underlying urologic condition or immunocompromising condition), the patient can be treated with an initial intravenous agent.

A urine culture and susceptibility testing should be obtained first for patients with risk factors for an MDR gram-negative infection.

For empiric treatment, unless the patient has a history of an isolate with documented resistance to these agents in the prior three months, oral options include (Hooten & Gupta, 2021; Hooten & Calderwood, 2020):

• Nitrofurantoin monohydrate/macrocrystals (Macrobid):
  • 100 mg orally twice daily for five days
• Fosfomycin:
  • 3 grams of powder mixed in water as a single dose
• Pivmecillinam (if available):
  • 400 mg orally three times daily for three to five days

If all of these are appropriate options based on patient circumstances (allergies, intolerances, drug interactions) and prior urinary isolates, nitrofurantoin is suggested. The use of fosfomycin should be reserved for documented MDR gram-negative infections or when nitrofurantoin is not an option and pivmecillinam is not as effective. In the US, resistance to all oral options is still uncommon among outpatients with E. coli cystitis.

Studies have suggested that nitrofurantoin, fosfomycin, and pivmecillinam retain clinical activity against some MDR organisms, including ESBL-producing isolates. For example, in a case-control study including 113 patients with ESBL-producing E. coli UTIs, no resistance to fosfomycin was detected, and clinical cure rates were high (93%). Some studies have evaluated a higher dose of fosfomycin (e.g., 3 g once every 2 to 3 days for 3 doses) for infections due to MDR organisms. Still, there is no evidence that this has greater efficacy than single-dose therapy (Hooten & Gupta, 2021; Hooten & Calderwood, 2020).

Suppose none of these can be used because of resistance or other concerns. In this case, antimicrobial therapy should be deferred until a regimen can be selected based on culture and susceptibility testing results. Studies among women without comorbidities have suggested that deferring antimicrobial therapy until these results are available is a safe strategy for simple acute cystitis.

Increasing antimicrobial resistance is found with simple acute cystitis that has a low risk of progression in patients without risk factors for serious infection. Antimicrobial sparing management strategies for some women with simple acute cystitis are of increasing interest but warrant further study before they can be routinely employed.

Delaying antimicrobial therapy while awaiting urine culture results appears reasonable in women without comorbidities if empiric therapy is complicated by resistance or drug intolerance. Substituting anti-inflammatory agents for antimicrobial therapy has also been evaluated but cannot be recommended as an initial approach to managing symptomatic simple acute cystitis. Additional studies are necessary.

Ms. Vinge is a 63-year-old, retired, Caucasian female who reports the acute onset of urinary frequency and urgency with gross hematuria beginning 0830 this morning. She denies fever, chills, rigors, flank pain, and CVA tenderness. She denies vaginal discharge or itching and reports no sexual activity in the past ten years. LMP 1999. No travel outside of the country since 2009.

Past Medical History:

• Osteoporosis-diagnosed 2005
• C-section Dec. 1989
• Tonsil & adenoid removal 1955

No known drug allergies

Current Medications:

• Ibandronate sodium 150 mg once a month
• Tylenol® 500 mg prn
• Motrin® 200 mg prn

Physical Examination:

• General: Afebrile.
• Neuro: Alert, oriented, cooperative, follows all commands appropriately.
• Eyes: PERRLA.
• HEENT: WNL.
• Lungs: CTA. No rales, rhonchi, or wheezes.
• Cardiac: HR 70 regular, regularity. No murmurs nor rubs. BP 130/70.
• Abdominal: Abdomen soft, non-tender with bowel sound in all quadrants. No CVA tenderness or suprapubic tenderness.
• GU: Urine cloudy with gross hematuria.
• PVS: No edema.

Midstream urine culture was collected and sent to the lab.

Results of urine culture showed Escherichia coli > 103 colony-forming units/mL.

The patient is considered to be at low risk for antimicrobial resistance.

TMP-SMX 160/800 mg orally ordered twice daily x 3 days.

Follow-up with MD scheduled in 1 week.