From the Guidelines
For an 83-year-old male with dementia and a suspected acute UTI, who is resistant to Macrobid, Septra, and Cipro, the best antibiotic choice would be a combination of Amoxicillin plus an aminoglycoside, as recommended by the European Association of Urology guidelines 1. This recommendation is based on the patient's complicated UTI and the need for effective treatment that considers the increasing prevalence of multidrug-resistant organisms in elderly patients. The use of a combination of Amoxicillin plus an aminoglycoside is a strong recommendation for the treatment of complicated UTIs 1. Alternatively, a second-generation cephalosporin plus an aminoglycoside could also be considered. It is essential to manage any urological abnormality and/or underlying complicating factors, as recommended by the guidelines 1. Additionally, the patient's renal function should be assessed before prescribing any antibiotic, as many elderly patients have decreased kidney function requiring dose adjustments. The management of urinary tract infections in frail or comorbid older individuals should take into account interactions with other drugs and possible side effects 1. Before starting any antibiotic, a urine culture should be obtained to confirm the diagnosis and guide definitive therapy based on susceptibility results. In this case, the patient's history of bladder cancer and dementia should be considered when selecting an antibiotic, and the treatment plan should be tailored to the individual's needs and medical conditions. The European Association of Urology guidelines provide a strong recommendation for the treatment of complicated UTIs, and this should be followed to ensure the best possible outcome for the patient 1. It is crucial to prioritize the patient's morbidity, mortality, and quality of life when selecting an antibiotic, and to choose an option that is effective and has a favorable safety profile. In this scenario, the combination of Amoxicillin plus an aminoglycoside is the most suitable option, considering the patient's complicated UTI and resistance to other antibiotics 1.
From the FDA Drug Label
The mechanism of action of levofloxacin and other fluoroquinolone antimicrobials involves inhibition of bacterial topoisomerase IV and DNA gyrase (both of which are type II topoisomerases), enzymes required for DNA replication, transcription, repair and recombination Fluoroquinolones, including levofloxacin, differ in chemical structure and mode of action from aminoglycosides, macrolides and β-lactam antibiotics, including penicillins Fluoroquinolones may, therefore, be active against bacteria resistant to these antimicrobials. Resistance to levofloxacin due to spontaneous mutation in vitro is a rare occurrence (range: 10-9 to 10-10). Cross-resistance has been observed between levofloxacin and some other fluoroquinolones, some microorganisms resistant to other fluoroquinolones may be susceptible to levofloxacin Levofloxacin has in vitro activity against Gram-negative and Gram-positive bacteria fections as described in Indications and Usage (1)
The best antibiotic choice for an 83-year-old male with dementia in long-term care with a remote history of bladder cancer presenting with gross haematuria suspicious for acute UTI but resistant to Macrobid, Septra, and Cipro would be Levofloxacin.
- Key points:
- Levofloxacin has a different mechanism of action compared to the resistant antibiotics.
- It has in vitro activity against Gram-negative and Gram-positive bacteria.
- Cross-resistance with other fluoroquinolones may occur, but some microorganisms resistant to other fluoroquinolones may still be susceptible to levofloxacin. 2
From the Research
Antibiotic Options for UTI in Elderly Patients
Given the patient's resistance to Macrobid (Nitrofurantoin), Septra (Sulfamethoxazole/Trimethoprim), and Cipro (Ciprofloxacin), alternative antibiotic options must be considered.
- The patient's age and dementia should be taken into account when selecting an antibiotic, as elderly patients may have decreased renal function and be more susceptible to adverse effects 3.
- For patients with a creatinine clearance of 30 mL/min or greater, nitrofurantoin may still be considered for short-term use, but this is not applicable in this case due to the patient's resistance 3.
Second-Line Options
- Oral cephalosporins, such as cephalexin or cefixime, may be considered as second-line options for treating UTIs in elderly patients 4.
- Fluoroquinolones, although not recommended as first-line treatment due to resistance concerns, may still be effective in some cases, but their use should be carefully considered 4, 5.
- β-lactams, such as amoxicillin-clavulanate, are also alternative options for treating UTIs in elderly patients 4.
Treatment of UTIs due to ESBL-Producing Enterobacteriales
- For UTIs caused by ESBL-producing E. coli, treatment options include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 4.
- For UTIs caused by ESBL-producing Klebsiella pneumoniae, treatment options include pivmecillinam, fosfomycin, finafloxacin, and sitafloxacin 4.
Parenteral Treatment Options
- Parenteral treatment options for UTIs due to ESBL-producing Enterobacteriales include piperacillin-tazobactam, carbapenems, ceftazidime-avibactam, and aminoglycosides, such as plazomicin 4.