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Acute uncomplicated lower urinary tract infection in a non-pregnant woman — MSRA MCQ

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HardUrinary Tract InfectionsAcute uncomplicated lower urinary tract infection in a non-pregnant womanMSRA

A 32-year-old non-pregnant woman was prescribed nitrofurantoin 100 mg modified-release twice daily for 3 days for acute dysuria, frequency and urgency. At presentation she had no fever, loin pain, vomiting, vaginal symptoms or relevant urinary tract history. Her eGFR was 86 mL/minute/1.73 m². A midstream urine sample sent before treatment has grown Escherichia coli reported as resistant to nitrofurantoin and susceptible to trimethoprim, pivmecillinam and fosfomycin. When contacted on day 3, she reports that all urinary symptoms resolved within 36 hours of starting treatment. She remains afebrile and has no loin pain, visible haematuria or systemic symptoms. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Prescribe no further antibiotic and advise review if symptoms recur, worsen or suggest upper UTI

Explanation lettering: B = shown as A · A = shown as B · D = shown as C · E = shown as D · C = shown as E

This is a non-pregnant woman with an uncomplicated lower UTI whose symptoms have resolved clinically despite a laboratory report of nitrofurantoin resistance. NICE advises reviewing culture results and changing therapy for resistant organisms only if symptoms are not already improving. She has completed the recommended 3-day nitrofurantoin course, has no features suggesting pyelonephritis, and does not need eradication treatment solely because the isolate is reported resistant. A, B and C are plausible because each is a culture-susceptible option for lower UTI. However, switching to another antibiotic after clinical resolution would add avoidable antimicrobial exposure without a guideline-based indication. D is inappropriate because routine test-of-cure urine culture is not indicated in an asymptomatic non-pregnant woman; bacteriuria without symptoms should not be sought or treated in this group. She should receive clear safety-netting to seek reassessment for recurrent urinary symptoms, fever, rigors, loin pain, vomiting or systemic deterioration.

Reference: NICE NG109: Urinary tract infection (lower): antimicrobial prescribing — Recommendations (Published 31 October 2018; minor update May 2025) — https://www.nice.org.uk/guidance/ng109/chapter/Recommendations NICE NG109: Urinary tract infection (lower): antimicrobial prescribing — Table 1 (Published 31 October 2018; minor update May 2025) — https://www.nice.org.uk/guidance/ng109/chapter/Recommendations NICE NG109: Urinary tract infection (lower): antimicrobial prescribing — Managing asymptomatic bacteriuria (Published 31 October 2018; minor update May 2025) — https://www.nice.org.uk/guidance/ng109/chapter/Recommendations