Case #1 Answers:
Answer 1
Differential diagnosis of acute dysuria in a young woman includes acute
cystitis, STDs with urethral involvement (N. gonorrhoeae, Chlamydia
trachomatis, and HSV - all not likely to present as acute urethritis in
females), and vaginitis. There is little information given in the case history
to allow prioritization.
Answer 2
Suprapubic pain and hematuria suggest acute cystitis. Attempt to determine if
the dysuria is internal (source urethral or bladder) or external (source
inflamed vulva from vaginitis). A sexual history including new partner, number
of recent/lifetime partners, date of most recent intercourse, history of
previous STD=s, form of contraception (condom and spermicide) should be
obtained. History of vaginal discharge and recent antibiotic use might indicate
vaginitis. All of these help to identify if she is at risk for STD=s,
intercourse-related cystitis, or vaginitis.
Answer 3
If
vaginal discharge is present on examination, saline and KOH wet preps are
indicated. If she had a new sex partner or multiple partners or a history of
exposure to STD=s diagnostic tests for N. gonorrhoeae and chlamydia are
indicated. To confirm diagnosis of UTI, a clean catch urine sample should be
obtained first. A urine dipstick demonstrating +leukocyte esterase with or
without hematuria would be suggestive of cystitis. Wet mount of a centrifuged
sample with 5-10 or more WBC=s per hpf would be strongly suggestive. Given the
predictability of bacteriology and susceptibility results, urine culture in an
uncomplicated UTI in a young healthy woman is not necessary.
Answer 4
E. coli
is most likely (80%), Staphylococcus saprophyticus is next most likely
(10-15%).
Answer 5
Recommended antimicrobial treatment for acute uncomplicated cystitis is
trimethoprim/sulfamethoxazole 160/800 BID, trimethoprim, norfloxacin,
ciprofloxacin, or ofloxacin for 3 days. Amoxicillin, cefadroxil, or
nitrofurantion have yielded less satisfactory results even with susceptible
organisms. Trimethoprim./sulfamethoxazole is most often recommended. In areas
where resistance of E. coli in this setting exceeds
15-20%, quinolones should be used. Single dose therapy with larger doses of
trimethoprim/sulfamethoxazole or quinolones are effective but associated with
lower rates of cure and more frequent recurrences.
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