From the Guidelines
For prophylaxis of recurrent multi-drug resistant organism (MDRO) extended-spectrum beta-lactamase (ESBL) urinary tract infections (UTIs) in elderly females, fosfomycin 3g oral powder every 10 days is recommended as first-line therapy, as supported by the most recent guidelines 1.
Key Considerations
- Alternative options include nitrofurantoin 50-100mg daily (if renal function allows, with eGFR >30 mL/min) or trimethoprim-sulfamethoxazole (TMP-SMX) 40/200mg three times weekly if susceptibility testing confirms effectiveness, as outlined in the guidelines 1.
- Prophylaxis duration typically ranges from 3-6 months, after which reassessment is needed, to balance the benefits of prevention against the risks of adverse events and antimicrobial resistance 1.
- Before starting prophylaxis, it is essential to confirm complete resolution of the active infection with a negative urine culture, to ensure that the prophylactic regimen is not initiated in the presence of an active infection 1.
Non-Antimicrobial Approaches
- Concurrent implementation of non-antimicrobial approaches is crucial, including:
- Adequate hydration (1.5-2L daily) to help prevent UTIs 1.
- Proper perineal hygiene and prompt post-void wiping front-to-back to reduce the risk of bacterial colonization 1.
- Consideration of vaginal estrogen cream for postmenopausal women to improve urogenital tissue integrity and reduce the risk of UTIs 1.
- Cranberry products (tablets or unsweetened juice) may provide additional benefit in reducing recurrent UTIs, although the evidence is not as strong for older adults or those with specific health conditions 1.
Monitoring and Follow-Up
- Regular monitoring for adverse effects and periodic urine cultures every 1-3 months are essential to assess the effectiveness of the prophylactic regimen and detect breakthrough infections 1.
- These prophylactic regimens work by maintaining sub-therapeutic antibiotic levels in the urine that prevent bacterial colonization while minimizing selection pressure for further resistance development, as supported by the guidelines 1.
From the FDA Drug Label
The recommended dosage for women 18 years of age and older for uncomplicated urinary tract infection (acute cystitis) is one sachet of fosfomycin tromethamine granules for oral solution. The FDA drug label does not answer the question.
From the Research
Prophylaxis for Recurrent MDRO ESBL UTI in Elderly Female
- The use of antibiotics such as nitrofurantoin, fosfomycin, and pivmecillinam has been shown to be effective in treating UTIs caused by ESBL-producing Enterobacteriaceae 2, 3, 4, 5.
- Nitrofurantoin has been specifically studied as a treatment option for ESBL-producing E. coli-related lower urinary tract infection, with clinical and microbiological success rates of 69% and 68%, respectively 6.
- The effectiveness of these antibiotics can vary depending on the specific organism and local susceptibility patterns, highlighting the importance of knowledge about common uropathogens and their resistance patterns 2, 3.
- In the case of recurrent MDRO ESBL UTI in elderly females, the use of oral antibiotics such as nitrofurantoin, fosfomycin, and pivmecillinam may be considered as a prophylactic measure, although the specific choice of antibiotic should be guided by the results of urine culture and susceptibility testing 4, 5.
- It is essential to use antibiotics judiciously and follow antimicrobial stewardship principles to minimize the risk of resistance development 2, 3.
Treatment Options
- Nitrofurantoin: effective against ESBL-producing E. coli and other Enterobacteriaceae 4, 5, 6.
- Fosfomycin: effective against ESBL-producing E. coli and other Enterobacteriaceae 2, 3, 4, 5.
- Pivmecillinam: effective against ESBL-producing E. coli and other Enterobacteriaceae 3, 4, 5.
- Other treatment options, such as ceftazidime-avibactam, meropenem/vaborbactam, and imipenem/cilastatin-relebactam, may be considered for more severe or complicated infections 2, 3.