Op-Med is a collection of original articles contributed by Doximity members.
I hear it time and time again. A request for cipro.
In a field where patients come in and out of the office for myriad complaints, a urinary tract infection can be a dime a dozen. For women especially, this can happen frequently, because of the way in which our bodies are built, with the proximity of our urethra to the rectum. Our bladder is also a shorter distance away, as compared with men, which doesn’t help matters much (note: this article is written specifically about women’s UTI). This is why I’ll often see female patients in my office, and under their chief complaint are just three letters: ‘UTI’.
Which, of course, is erroneous, because a chief complaint should be a symptom, not a diagnosis. It should be exactly as it sounds: a chief ‘complaint.’ Examples are ‘cough’ or ‘tingling fingers,’ or in this case, ‘frequency urinating.’ It’s crucial to make that distinction because many times a patient may feel like they are having a UTI when, in fact, they’re experiencing something completely different.
The other day I had a male patient who had that exact chief complaint typed into his chart, yet he ended up diagnosed with diverticulitis, an infection of his intestine, a different organ system altogether. Another patient, a young female, came in with a similar presentation, but she had no bacteria in her urine on culture. I ended up diagnosing her with a yeast infection instead. Other possibilities also exist, this we know.
In general, however, with UTIs, my patients are usually correct in their presumption. They know what they’re feeling, especially when it’s something that they’ve felt before. This is also why an infection like this can sometimes be treated empirically, without testing.
Until fairly recently, ciprofloxacin was the go-to medication for the treatment of a run-of-the-mill UTI. But that has changed. Cipro is no longer recommended in the treatment of a UTI in females. Not as first line, or even second, for that matter. Some hospitals have even gone as far as limiting access to its use.
So why are we still prescribing it? Why are doctors everywhere still doling out this heavily resistant, side-effect-prone, no longer recommended antibiotic of yesteryear? Don’t get me wrong, it’s a powerful one, indeed. But in my practice, and in those all over the country, we are seeing more and more sensitivity profiles showing resistance to this drug. Why? Because it’s been overused. Every phone call, and office visit for that matter, to the doctor was followed in the past by a reflexive ‘Cipro-call’ into the pharmacy. Women held on to their extras in their bathroom cabinets, for just-in-case. But we’re now on the forefront of a worldwide antibiotic resistance crisis. If you click into the underlined link, pay special attention to the Scope section, and follow it up by reading on Prevention and Control.
In addition to the resistance aspect, just last year, the FDA came out with a very strong warning, reminding practitioners of the dangers of flurouquinolones, a class of antibiotics of which Cipro is a member. While its adverse effect profile is extensive, the FDA chose to focus on tendonitis and tendon rupture as one of the main causes for alarm. Did some of us miss this? Quite possibly.
According to the latest guidelines published on up-to-date (our bible), the first line treatment of an outpatient, uncomplicated UTI is an antibiotic called nitrofurantoin, under the brand name of ‘Macrobid’ or ‘Macrodantin.’ It is, in fact, given twice daily, as opposed to the old Cipro, normally given in a convenient once daily dosing, but it’s the first line medication at this point in time and should be utilized as such. Allergies and other aspects of treatment-specifics should, of course, be considered on a per-patient basis, by the medical practitioner (we’ve been through so much training for a reason).
So why am I seeing Cipro over and over again? Why am I hearing feedback from patients, about doctors who give it first-line? Why am I treating resistant strains, increasingly present in my patients’ culture growth, when they retrun for ‘another round of UTI’?
What happened to following guidelines and why is it important to follow them?
It’s important because we want to do things right. We want to treat patients based on data, the research that goes into finding the right medicines, yielding the right numbers. We also want to do it because of the future of our children. To give them more options when they’re older and they’re sick. Because when we follow guidelines, we not only increase the chances of properly treating infections, but also decrease the spread of antibiotic resistance. Isn’t that ultimately what we all want?
Dana Corriel, MD is a board-certified internist, who heads the clinic at Pearl River Internal Medicine. She also serves as the Director of Quality for Highland Medical, PC. When Dr. Corriel is not ‘doctoring’, she is a mother to three rambunctious boys. In her spare time, she enjoys crafting commentaries on her website, as well as initiating discussion on social media that are central to the field of medicine. Her goal is to humanize the face of medicine.