Case 2

A 25-year-old woman with past medical history significant for remote UTIs presented with dysuria, urinary
frequency, urgency, and a one-time episode of hematuria. She denied fever, chills, nausea, vomiting, or back pain.
She reported that she did not feel particularly sick and stated that she was not pregnant. She had no recent history of
surgical procedures or hospitalizations. Urine dipstick test results were positive for leukocyte esterase and nitrates.
She was presumed to have an uncomplicated UTI and was prescribed a 5-day course of nitrofurantoin. Two days
after her presentation, urine culture results were positive for Pseudomonas aeruginosa, resistant to ciprofloxacin.
How would you manage this case?

Discussion. Pseudomonas species are ubiquitous gram-negative bacteria, and P aeruginosa is the most important
species in human infections.12 P aeruginosa is among the main pathogens in community-onset health-care–associated
UTI.13 In a surveillance study conducted from 2009 to 2010, P aeruginosa was the second most common pathogen in
catheter-associated UTIs, accounting for 11.3% of all cases in the United States. 14 It also is a very common pathogen
in intensive care and long-term acute care settings.15,16

In contrast, UTI from P aeruginosa is rare in the community, with an occurrence rate of 1% to 4%.13 However, the
positivity of this pathogen in urine culture in community-onset UTI has some implications. Studies have revealed
that Pseudomonas UTI is suggestive of underlying urologic conditions such as prostatitis, urinary tract obstruction, a
history of urologic procedures or neurogenic bladder, and prior UTI treatment. Many of these risk factors suggest
that the patients have had health care exposure; therefore, these infections may not be community-acquired but are
likely health-care–associated.12

The antimicrobial resistance rate is high among P aeruginosa strains. Only 2 antimicrobial classes, fluoroquinolones
and fosfomycin, are effective as oral options. Among fluoroquinolones, ciprofloxacin and levofloxacin are well
known to have activity against susceptible P aeruginosa strains. Although it is not widely recognized, fosfomycin
can have activity against P aeruginosa in varying degrees.17 The antibiotic penetration of fosfomycin in the lower
urinary tract is excellent, and it can be an effective option if the P aeruginosa strain is susceptible to it.

Outcome of the case. Despite having denied any recent health care contact (hospital admissions, surgical
procedures, urinary catheter placements, antibiotic prescriptions), the patient did mention having had 7 UTI episodes
since childhood. She received a diagnosis of P aeruginosa cystitis. Additional testing for fosfomycin sensitivity was
requested, the results of which confirmed susceptibility a few days later.

The patient was instructed to take fosfomycin orally as 3 g of powder mixed with at least ½ cup of water every 3
days for a total of 3 doses, after which her symptoms resolved. Urine human chorionic gonadotropin testing was not
done, since fosfomycin is known to be safe in pregnancy. In light of the patient’s community-onset P
aeruginosa UTI and her history of frequent UTIs, she was referred her a urology clinic to rule out anatomic or
functional problems in her genitourinary tract.

Case 3

An 82-year-old man taking tamsulosin for BPH presented with a 2-day history of dysuria. He reported that he had
had 3 UTIs in the past 2 months. A review of his medical records revealed that he had had 3 positive urine culture
results for pan-susceptible E coli 7 weeks ago, 4 weeks ago, and again 2 weeks ago. He had experienced dysuria,
perianal discomfort, and cloudiness of urine intermittently during these episodes, but he denied fever, chills, and
flank pain. He had received 10 days of ciprofloxacin for the first episode, 10 days of nitrofurantoin for the second
episode, and 10 days of TMP-SMX for the third and most recent episode.

At the current visit, urine dipstick test results were positive for leukocyte esterase and nitrates. Urine culture grew E
coli that was pan-susceptible (including to ciprofloxacin). Results of CT scan with contrast of the abdomen/pelvis
were unremarkable.

What is the most likely diagnosis and treatment approach?

Discussion. In the absence of fever, this elderly patient with BPH presenting with recurrent UTI is unlikely to have
pyelonephritis. Identification of the same E coli strain in repeated urine cultures raises several possibilities, including
asymptomatic bacteriuria, infected nephrolithiasis, abscess, and chronic prostatitis.

Asymptomatic bacteriuria is a microbiologic diagnosis determined with the results of a urine specimen that has been
collected in a manner to minimize contamination and that has been transported to the laboratory in a timely fashion
to limit bacterial growth. Asymptomatic bacteriuria occurs not only in women but also in men, 18 particularly those
who have diabetes (0.7%-11%),19 who are elderly persons in the community (3.6%-19%),20 and elderly persons in a
long-term care facility (15%-40%).21 Our patient presented with positive urine culture results and correlating
symptoms; therefore, this is not a case of asymptomatic bacteriuria.

UTI from a nidus of infection is another possibility. Infected nephrolithiasis in the ureter or the bladder can present
with recurrent UTI from the same bacterial strain. Renal abscess resulting from severe pyelonephritis also can
present with persistent bacteriuria from the same strain until its resolution. CT imaging can help rule out these
anatomic problems.

Chronic prostatitis should be in the differential diagnosis in men with recurrent UTI. Chronic bacterial prostatitis is
characterized by repeatedly positive urine culture results for the same organism strain. 22 In contrast with acute
bacterial prostatitis (which is characterized by abrupt-onset fever, chills, dysuria, and the striking physical finding of
severe prostate tenderness), patients with chronic prostatitis are often asymptomatic between episodes of bacteriuria.
The prostate is usually normal on DRE. Often, the bacterial strain remains antibiotic-sensitive on culture tests
repeated after multiple antibiotic courses.23

A diagnosis of chronic bacterial prostatitis can be confirmed by means of culture of the prostatic fluid with the use of
classic Meares-Stamey 4-glass test.9 In this test, the patient voids the first 10 mL of urine (the urethral specimen;
VB1) into a collection glass. After the patient voids approximately 200 mL, a midstream specimen (bladder urine;
VB2) is collected. After the bladder has been emptied, expressed prostatic secretions (EPS) are obtained after
prostatic massage. The first 10 mL of urine voided after massage (VB 3) is considered to be prostatic washout. The
presence of the same bacteria in the EPS and VB3 samples as in the VB1 and VB2 samples is highly diagnostic of
bacterial prostatitis. Growth of gram-negative bacilli in the VB 1 specimen without substantial growth in the other
samples is diagnostic of urethral colonization. Unfortunately, sensitivity and specificity have not been well
established.

The prostate is unique in that only limited classes of antibiotic can penetrate it effectively. The first-line therapy for
chronic prostatitis is a fluoroquinolone for 4 to 6 weeks, which generally results in microbiologic cure rates of 70%
or more.24,25 Of note, tendinopathy with prolonged fluoroquinolone use has been reported frequently, prompting the
Food and Drug Administration to mandate a black-box warning on the package labeling. Patients should be informed
about the risks and benefits of the use of this class of medication.

Outcome of the case. In the light of the recurrent UTI symptoms, the multiple positive urine cultures for the same
organism type, and the negative CT findings, the most likely diagnosis was chronic prostatitis. The patient deferred a
DRE. Empiric treatment with ciprofloxacin for 6 weeks was prescribed, after which his symptoms resolved.