comment on alternative treatment of pyelonephritis or additional treatment options
Hello this a discussion response to..I would like to comment on alternative treatment of pyelonephritis or additional treatment options..please use scholarly resources published within 5 years in the USA..thank you.
original post below…..
Pertinent positives of M. C.’s review of systems include fever, fatigue, decreased appetite, occasional nausea, dysuria, urinary frequency, urinary urgency, and flank pain. Pertinent negatives of her review of systems include the absence of chills, vomiting, hematuria, vaginal/urethral discharge, or discomfort. Pertinent positives on her physical exam include fever and right CVA tenderness. Pertinent negatives include a normal heart rate, absence of vomiting, normal urethra without discharge, redness, or tenderness.
While dysuria can be associated with urethritis, I am less likely to diagnose her with urethritis today based on her associated symptoms and her physical exam (negative urethral discharge and erythema). While I am less concerned with urethritis, I still encourage STI screening. A wet prep was obtained, and trichomonas was not detected. GC/chlamydia PCR endocervical swab was obtained and not detected. The patient was offered other STI screening, including a hepatitis panel, HIV, and syphilis. Those results are pending.
A UA was obtained and showed the following:
Positive leukocyte esterase
Epithelial cells <5
A urine HCG was obtained to rule out pregnancy since the patient is sexually active. The result was negative. The urine was also sent for culture. Since her UA does not indicate hematuria, I am less likely to suspect a kidney stone. Other diagnoses should be considered if hematuria is not seen in the urinalysis (Fontenelle & Sarti, 2019). Her pain has also been progressive over time and less abrupt.
Today I will diagnose and treat M. C. for acute pyelonephritis. When the patient is not at high risk of infection with a multidrug-resistant organism, outpatient oral therapy can be initiated with a fluoroquinolone or trimethoprim/sulfamethoxazole (Gupta et al., 2011). Outpatient management is appropriate in uncomplicated cases if the patient can tolerate oral therapy, is hemodynamically stable, and does not require IV fluids (Harness et al., 2020). Currently, she can eat and drink without difficulty. Her vital signs are stable. If the prevalence of resistance of community uropathogens to fluoroquinolones is not known to exceed 10%, then they can be prescribed (Gupta et al., 2011). My prescription for the antibiotic is as follows:
Ciprofloxacin 500mg tablets
Sig: 500mg by mouth twice daily for 7 days
Disp: 14 tablets
(Gupta et al., 2011)
Supportive care includes antipyretics, analgesics, and antiemetic medications (Harness et al., 2020). I would encourage the patient to continue Tylenol and Ibuprofen as needed for fever and discomfort. She can follow the directions on the medication bottle for this. I would also prescribe an antiemetic for her occasional nausea. The prescription for the antiemetic is as follows:
Ondansetron (Zofran) 4mg ODT
Sig: 4mg by mouth every 6 hours as needed
The patient will be instructed to complete the entire course of antibiotics, even if symptoms subside and feeling better before treatment is complete (Dunphy et al., 2019). Adequate hydration is essential. Increase fluid intake to 8-10, eight oz glasses of water each day (Dunphy et al., 2019). Consider a cranberry supplement or cranberry juice as this can help decrease the bacteria adhering to the cells that line the bladder (Dunphy et al., 2019).
Common side effects of ciprofloxacin include nausea, vomiting, diarrhea, and rash (Epocrates, 2022). Avoid taking ciprofloxacin alone with dairy products or calcium-fortified juice (Epocrates, 2022). If a dose is missed and greater than 6 hours before the next dose, take the missed dose, but if it is less than 6 hours before the next dose, skip that dose and resume the next scheduled dose (Epocrates, 2022). This medication can have some severe side effects. Contact the office if you develop a headache, confusion, agitation, paranoia, suicidal ideation, or sudden pain in your joints (Epocrates, 2022).
The ciprofloxacin may decrease the effectiveness of the oral contraceptive (Epocrates, 2022). I would encourage a backup method such as condoms during treatment and one week after treatment to reduce the chance of pregnancy. The ondansetron is an oral disengaging tablet (ODT) and should be placed in the mouth and allowed to dissolve before swallowing to help with nausea (Epocrates, 2022).
Follow-up and referral
Patients with acute pyelonephritis being treated outpatient should be re-evaluated in 48-72 hours, and the urine culture results should be reviewed when available to ensure susceptibility to the prescribed antibiotic (Harness et al., 2020). M. C. will be scheduled for a follow-up in 48 hours. She will be educated to contact the office if her condition worsens or present to the nearest emergency department. If the patient has not improved at her 48-hour follow-up visit, I will contact urology for a consult if available or consider sending the patient to the emergency department for further evaluation and treatment.