Answer to the last #DiagnosticDilemma
The correct answer is B. Nitrofurantoin

This older adult patient most likely has cystitis and should begin nitrofurantoin therapy. Although the most common symptoms of cystitis in premenopausal women are dysuria, frequency, urgency, and suprapubic discomfort, postmenopausal women with cystitis may experience incontinence. Fever is unusual.

The treatment of cystitis in older adults who do not have significant concurrent medical illnesses is the same as that used in younger patients. This patient should begin nitrofurantoin, 100 mg twice daily for 5 days. Nitrofurantoin should not be used in patients whose creatinine clearance is less than 50 mL/min. Trimethoprim-sulfamethoxazole, one double-strength tablet twice daily for 3 days, is first-line therapy in the absence of a sulfa allergy and if local E. coli resistance to trimethoprim-sulfamethoxazole is less than 20%.

Fluoroquinolones, such as levofloxacin and ciprofloxacin, are considered second-line therapy because of their higher cost and the concern for emergence of resistance with widespread use.

• Treatment is indicated in all patients with symptomatic cystitis, and nitrofurantoin for 5 days is the regimen of choice in patients allergic to sulfa drugs.


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