Case 1: Pyelonephritis is typically caused by a bacterium infecting the kidneys. Bacteria can move to the kidneys from the bladder or can be carried through the bloodstream from other parts of the body. Although many bacteria can cause pyelonephritis, Escherichia coli is most often the cause.
In patients suspected of having pyelonephritis or who are being treated for it on an outpatient basis, oral ciprofloxacin 500 mg twice daily for 7 days is an appropriate choice (as long as fluoroquinolone resistance in the area is not known to exceed 10%). Alternatively, ciprofloxacin 1000 mg extended release for 7 days or levofloxacin 750 mg once daily for 5 days is also acceptable.
Case 2: Insomnia symptoms occur in about 33% to 50% of adults. According to American Academy of Sleep Medicine guidelines, insomnia is defined as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity, and results in some form of daytime impairment.
The primary goals of insomnia treatment are to improve sleep quality and quantity and improve associated daytime impairment. Guideline-recommended pharmacologic treatments include short-acting benzodiazepine receptor agonists (ie, zolpidem, eszopiclone, zaleplon, and temazepam) or ramelteon. While other potential agents exist, including sedating antidepressants (trazodone, amitriptyline, doxepin, mirtazapine), antiepilepsy medications (gabapentin, tiagabine), and atypical antipsychotics (quetiapine, olanzapine), these are most suitable for people who have comorbid conditions that may benefit from the primary action of these drugs (ie, depression, epilepsy/seizures, or psychosis). OTC sleeps aids (antihistamines) or natural products (valerian, melatonin) are not recommended for chronic insomnia because of their relative lack of efficacy and safety data. Regardless of the agent chosen, the lowest possible dose to treat the insomnia should be employed.
CC’s insomnia may be due to frequent travel or the recent stress of a significant illness. It appears that CC’s insomnia is characterized by difficulty falling asleep, and not staying asleep. Because CC does not suffer from any comorbid conditions that would benefit from a specific agent, a trial of a short-acting benzodiazepine seems appropriate. Zolpidem 5 mg once per night, taken immediately before bedtime and with at least 7 to 8 hours remaining before the planned time of awakening, should aid CC in falling asleep. If the 5-mg dose is not effective, the dose can be increased to 10 mg.