Treatment Decisions regarding the initiation of antiretroviral therapy should be guided by monitoring the laboratory parameters of HIV RNA (viral load) and CD4+ T-cell count, and the clinical condition of the patient. The primary goals of antiretroviral therapy are maximal and durable suppression of viral load, restoration or preservation of immunologic function, improvement of quality of life, reduction of HIV-related morbidity and mortality, and prevention of HIV transmission. Antiretroviral therapy should be initiated in all women with a history of an AIDS-defining illness or with a CD4 count less than 350 cells per mm3 . Antiretroviral treatment should be started regardless of CD4 count in women with the following conditions: pregnancy, HIV-associated nephropathy, and hepatitis B coinfection when treatment of hepatitis B is indicated. Patients must be willing to accept therapy to avoid the emergence of resistance caused by poor compliance. Dual nucleoside regimens used in addition to a protease inhibitor or nonnucleoside reverse transcriptase inhibitor provide a better durable clinical benefit than monotherapy.
Patients with less than 200 CD4+ T cells per μL should receive prophylaxis against opportunistic infections, such as trimethoprim/sulfamethoxazole or aerosol pentamidine for the prevention of PCP pneumonia. Those with less than 50 CD4+ T cells per uL should receive azithromycin prophylaxis for mycobacterial infections (54).
Acute Cystitis Women with acute cystitis generally have an abrupt onset of multiple, severe urinary tract symptoms including dysuria, frequency, and urgency associated with suprapubic or low-back pain. Suprapubic tenderness may be noted on physical examination. Urinalysis reveals pyuria and sometimes hematuria. Several factors increase the risk for cystitis, including sexual intercourse, the use of a diaphragm and a spermicide, delayed postcoital micturition, and a history of a recent urinary tract infection (55–57).
Diagnosis Escherichia coli is the most common pathogen isolated from the urine of young women with acute cystitis, and it is present in 80% of cases (58). Staphylococcus saprophyticus is present in an additional 5% to 15% of patients with cystitis. The pathophysiology of cystitis in women involves the colonization of the vagina and urethra with coliform bacteria from the rectum. For this reason, the effects of an antimicrobial agent on the vaginal ﬂora play a role in the eradication of bacteriuria.
Treatment High concentrations of trimethoprim and ﬂuoroquinolone in vaginal secretions can eradicate E. coli while minimally altering normal anaerobic and microaerophilic vaginal ﬂora. An increasing linear trend in the prevalence of resistance of E. coli (>10%) to the ﬂuoroquinolones (e.g., ciproﬂoxacin) was noted. Despite a similar increase in E. coli resistance (9%–18%) to trimethoprim/sulfamethoxazole, therapeutic efficacy remains stable. In contrast, no such increase in resistance was noted with nitrofurantoin. Nitrofurantoin (macrocrystals, 100 mg orally twice daily for 5 days) or trimethoprim/sulfamethoxazole 160/800 mg orally twice daily for 3 days) are the optimal choices for empirical therapy for uncomplicated cystitis (59).
In patients with typical symptoms, an abbreviated laboratory workup followed by empirical therapy is suggested. The diagnosis can be presumed if pyuria is detected by microscopy or leukocyte esterase testing. Urine culture is not necessary, and a short course of antimicrobial therapy should be given. No follow-up visit or culture is necessary unless symptoms persist or recur.