Guidelines for management of the problem patient

Most lower urinary tract infections in women are uncomplicated and are treated by gynecologists or family physicians. The problem patient may require a thorough workup to identify the causative organism or underlying pathology. A hypothetical case example is presented in which Klebsiella is identified as the pathogen. A cephalosporin is administered for seven days with reculture twenty-four hours after completion of therapy. If the urine proves to be sterile, a bedtime regimen is initiated of nitrofurantoin macrocrystals, 100 mg. The objective is to target the bladder with a potent bactericidal agent that will not create resistant bacterial strains or have side effects. After two weeks, dosage is reduced to every other night for two to four weeks. If the patient continues to have recurrences, short-course self-medication is indicated. In addition to the patient with recurrent infections, other problem patients include the patient with nosocomial infection, immunocompromised patients, infants and preschool children, and the elderly.