MKSAP: 38-year-old woman with fever and flank pain

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 38-year-old woman undergoes follow-up evaluation in the office. She was evaluated in the emergency department 3 nights ago with fever and flank pain following 2 days of dysuria.

A urine culture and two sets of blood cultures were collected. She was given intravenous ceftriaxone and discharged with a 7-day course of ciprofloxacin. She is now asymptomatic. Medications are ciprofloxacin and an oral contraceptive.

On physical examination, vital signs and other findings are normal.

Escherichia coli susceptible to ciprofloxacin was isolated from her urine culture and one blood culture.

Which of the following is the most appropriate management?

A. Completion of oral ciprofloxacin course
B. Completion of oral ciprofloxacin course with follow-up blood cultures
C. Extended oral ciprofloxacin therapy for 2 weeks
D. Intravenous ceftriaxone
E. Kidney ultrasonography

MKSAP Answer and Critique

The correct answer is A. Completion of oral ciprofloxacin course.

This patient should complete her prescribed 7-day course of oral ciprofloxacin. She has acute uncomplicated pyelonephritis, which can usually be managed with outpatient oral antimicrobial therapy. Ciprofloxacin for 1 week or levofloxacin for 5 days are the recommended first-line treatment regimens. An initial dose of a long-acting parenteral antibiotic (such as ceftriaxone or aminoglycoside) is suggested when local fluoroquinolone resistance (>10%) is a concern. When a fluoroquinolone antibiotic cannot be used or the bacterial isolate proves resistant, an alternative second-line oral antibiotic should be substituted. Available options include trimethoprim-sulfamethoxazole or the less well-studied oral β-lactam agents.

With the exception of pregnancy, follow-up microbiologic cultures and urinalysis are not required or indicated after resolution of infection.

Extending the duration of ciprofloxacin therapy beyond 7 days would be warranted for complicated pyelonephritis but should not be influenced by the discovery of the single bloodstream isolate in this otherwise healthy woman.

Transient bacteremia does not necessitate hospitalization for parenteral antimicrobial therapy except when the pathogen is found to be multidrug resistant or when complicating features are present (severe illness, obstruction, pregnancy).

In adult women with acute kidney infections, urinary tract imaging by ultrasonography or CT is not routinely performed. However, urologic imaging may be useful and is recommended in evaluating patients who do not clinically improve after 72 hours of adequate antimicrobial therapy or when complications such as obstruction or perinephric and renal abscesses are suspected. Such studies should also be considered when evaluating women who experience an excessive number of recurrent urinary tract infections.

Key Point

  • Acute, uncomplicated pyelonephritis can usually be managed with oral outpatient antimicrobial therapy, with the fluoroquinolones ciprofloxacin and levofloxacin being the preferred, first-line agents.

This content is excerpted from MKSAP 18 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 18 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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