On the third day of hospitalization, a 34-year-old woman is re-evaluated during morning ro… — USMLE Step 2 CK

On the third day of hospitalization, a $34$ -year-old woman is re-evaluated during morning rounds. She was initially admitted for severe right flank pain, dysuria, nausea, and a temperature of $39.2^\circ\text{C}$ ( $102.6^\circ\text{F}$ ). She was empirically started on intravenous ceftriaxone for acute pyelonephritis. Today, the patient reports significant improvement in her symptoms and has tolerated a regular diet since yesterday evening. Her temperature is $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure is $118/76\text{ mm Hg}$ , and pulse is $78/\text{min}$ . Right costovertebral angle tenderness is no longer present. Blood cultures obtained at admission have shown no growth. Urine culture results are now available and demonstrate $>10^5\text{ CFU/mL}$ of *Escherichia coli*. The organism is susceptible to ciprofloxacin, ceftriaxone, and meropenem; it is resistant to ampicillin and trimethoprim-sulfamethoxazole. Based on the patient's current clinical status and laboratory findings, which of the following is the most appropriate next step in management?

Switch to oral ciprofloxacin and plan for dischargeAnswer
B
Continue intravenous ceftriaxone to complete a 7-day course
C
Switch to oral trimethoprim-sulfamethoxazole and plan for discharge
D
Escalate therapy to intravenous meropenem
E
Obtain a repeat urine culture to document bacterial clearance

Answer

The most appropriate next step is to switch the patient to oral ciprofloxacin and plan for discharge.

The correct management for a patient admitted with acute pyelonephritis who demonstrates significant clinical improvement, is hemodynamically stable, and can tolerate oral intake is to transition from intravenous to oral antibiotics. Because the urine culture grew *Escherichia coli* susceptible to ciprofloxacin, and fluoroquinolones have excellent oral bioavailability with high tissue penetration in the urinary tract, transitioning to oral ciprofloxacin is the optimal choice. This evidence-based practice minimizes hospital length of stay and avoids complications associated with prolonged intravenous catheter use.

Step-by-Step Solution

Assess the patient's clinical trajectory.

The patient is afebrile (

37.1^\circ\text{C}

), hemodynamically stable, has resolving symptoms, and is tolerating oral intake.

Determines readiness for transition from inpatient intravenous therapy to outpatient oral therapy.

Evaluate microbiological data and susceptibilities.

Urine culture confirms *E. coli* resistant to TMP-SMX but susceptible to ciprofloxacin.

Ensures the planned oral step-down agent is active against the specific identified pathogen.

Select the appropriate definitive oral therapy.

Oral ciprofloxacin is chosen because the organism is susceptible and fluoroquinolones achieve excellent tissue penetration in the urinary tract.

Allows for safe hospital discharge while completing the required treatment course with a highly bioavailable oral drug.

Key Concept

Patients admitted with acute pyelonephritis should be transitioned from intravenous to targeted oral antibiotics once they demonstrate clinical improvement (afebrile for

24

48

hours, resolving symptoms) and can tolerate oral intake.

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