What antibiotic (abx) regimen is recommended for a 74-year-old female with a urinary tract infection (UTI) caused by Escherichia coli (E. coli), a history of chronic kidney disease (CKD) and heart failure (HF)?

From the Guidelines

For a 74-year-old female with a UTI caused by E. coli who also has CKD and heart failure, the recommended antibiotic regimen would be nitrofurantoin 100 mg orally every 12 hours for 7 days, with careful monitoring of renal function and adjustment of dose as necessary, as it has minimal resistance and propensity for collateral damage, and is considered an appropriate choice for therapy in patients with CKD 1. The choice of antibiotic is crucial in this patient population, and the most recent and highest quality study recommends nitrofurantoin as a first-line treatment for uncomplicated UTIs, including in patients with CKD 1.

• The patient's history of CKD and heart failure requires careful consideration of the potential side effects of antibiotics, such as fluid retention with trimethoprim-sulfamethoxazole and tendon rupture with fluoroquinolones.
• Local resistance patterns and previous culture results should also be taken into account when selecting an antibiotic regimen.
• Close monitoring for side effects is essential in this patient population, and the patient's renal function should be closely monitored during treatment with nitrofurantoin.
• The dose of nitrofurantoin may need to be adjusted based on the patient's renal function, and the patient's nephrologist should be consulted to determine the best course of treatment.
• Other antibiotics, such as trimethoprim-sulfamethoxazole and fluoroquinolones, may be considered as alternative treatments, but their use should be carefully weighed against the potential risks and benefits in this patient population 1.

From the FDA Drug Label

Adult Patients: Urinary Tract Infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, Providencia rettgeri, Morganella morganii, Citrobacter diversus, Citrobacter freundii, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus epidermidis, Staphylococcus saprophyticus, or Enterococcus faecalis Acute Uncomplicated Cystitis in females caused by Escherichia coli or Staphylococcus saprophyticus.

The patient has a Urinary Tract Infection (UTI) caused by Escherichia coli (E. coli), and the recommended antibiotic regimen is ciprofloxacin (PO), as it is indicated for the treatment of UTIs caused by E. coli in adult patients, including females with acute uncomplicated cystitis. However, it is essential to consider the patient's history of CKD and HF and adjust the dosage accordingly, as the label does not provide specific recommendations for patients with these conditions. 2

From the Research

Antibiotic Regimen for UTI in a 74-year-old Female with CKD and HF

• The patient has a urinary tract infection (UTI) caused by Escherichia coli (E. coli) with a history of chronic kidney disease (CKD) and heart failure (HF) 3, 4.
• European guidelines on urological infections recommend antimicrobial treatment only for symptomatic UTIs 3.
• The choice of antibiotic should be based on the susceptibility of the E. coli isolate and the patient's underlying medical conditions, including CKD and HF 5, 6.
• Amoxicillin-clavulanate may be a useful alternative therapy for the treatment of ceftriaxone non-susceptible Enterobacterales UTIs 5.
• Resistance rates to commonly used antibiotics, such as ciprofloxacin, cotrimoxazole, and amoxicillin-clavulanic acid, should be considered when selecting an antibiotic regimen 6.
• Previous hospitalization in the last 3 months, hematological malignancy, and renal transplantation are risk factors for resistance to certain antibiotics and should be taken into account when choosing an antibiotic 6.
• The diagnosis of symptomatic UTI should be made based on clinical features and laboratory evidence, including a positive urine culture and pyuria 7.
• Antibiotics should be selected based on the uropathogen, local resistance rates, and adverse effect profiles 7.

Considerations for Antibiotic Selection

• The patient's CKD and HF should be considered when selecting an antibiotic regimen, as some antibiotics may be contraindicated or require dose adjustment in patients with these conditions 3, 4.
• The potential for antibiotic resistance and the risk of treatment failure should be considered when selecting an antibiotic regimen 5, 6.
• The patient's symptoms and clinical presentation should be carefully evaluated to ensure that the antibiotic regimen is appropriate for the severity and complexity of the UTI 7.