What is the first line antibiotic (abx) for a 74-year-old male presenting with dysuria?

From the Guidelines

For a 74-year-old male with dysuria, the recommended first-line antibiotic treatment is nitrofurantoin monohydrate/macrocrystals at a dose of 100 mg twice daily for 5-7 days. This recommendation is based on the high estimated clinical efficacy of 93% and microbiological efficacy of 88% as reported in the 2011 Clinical Infectious Diseases guidelines 1. Although the guidelines are specifically for acute uncomplicated cystitis and pyelonephritis in women, the principles of antibiotic selection can be applied to men, considering the similar pathogens involved.

When considering alternative options, trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) is another choice with a high estimated clinical efficacy of 93% and microbiological efficacy of 94% 1. However, the choice between nitrofurantoin and trimethoprim-sulfamethoxazole should consider local resistance patterns and the patient's specific health status.

Key points to consider in the management of this patient include:

• Obtaining a urine culture to guide therapy if the initial empiric treatment fails
• Encouraging adequate hydration during treatment
• Completing the full course of antibiotics even if symptoms improve quickly
• Considering the higher risk of complicated UTI in older men, with potential prostatic involvement requiring agents with good prostate penetration
• Prompt reevaluation if symptoms don't improve within 48-72 hours, or if fever, flank pain, or systemic symptoms develop, as this may indicate a more complicated infection requiring different management.

It's also important to note that fluoroquinolones, such as ciprofloxacin, are not typically the first choice for uncomplicated UTIs in elderly patients due to concerns about resistance and side effect profiles 1. Fosfomycin trometamol, a single-dose regimen, may be considered in certain cases, especially where resistance to other agents is a concern, but its use is generally guided by specific clinical scenarios and local resistance patterns 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to empiric selection of therapy Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris It is recommended that initial episodes of uncomplicated urinary tract infections be treated with a single effective antibacterial agent rather than the combination

First-line antibiotic treatment for a 74-year-old male with dysuria may include trimethoprim-sulfamethoxazole (PO), as it is indicated for the treatment of urinary tract infections due to susceptible strains of certain organisms, including Escherichia coli and Klebsiella species 2.

• Key considerations include:
  • Local epidemiology and susceptibility patterns
  • Culture and susceptibility information, when available
  • The recommendation to use a single effective antibacterial agent for initial episodes of uncomplicated urinary tract infections

From the Research

First-Line Antibiotics for a 74-Year-Old Male with Dysuria

• The patient's symptoms and age should be considered when selecting an antibiotic 3.
• For men with lower UTI symptoms, first-line antibiotics include:
  • Trimethoprim for seven days
  • Trimethoprim/sulfamethoxazole for seven days
  • Nitrofurantoin for seven days 3
• Uncomplicated UTIs in nonfrail men 65 years and older with no relevant comorbidities necessitate a urine culture with susceptibility testing to adjust the antibiotic choice after initial empiric treatment 3.
• Other studies suggest that nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are appropriate first-line therapies for uncomplicated cystitis 4, 5, 6.
• However, the choice of antibiotic should take into account the patient's individual risk factors for resistance and regimen tolerability 5.

Considerations for Antibiotic Resistance

• Increasing resistance rates among uropathogens have complicated treatment of acute cystitis 5.
• Resistance is increasing to fluoroquinolones, beta-lactams, and trimethoprim-sulfamethoxazole 6.
• Most uropathogens still display good sensitivity to nitrofurantoin 6.
• The use of new antimicrobials should be done wisely to avoid resistance development 4.