What antibiotic should be used for an 85-year-old female with a urinary tract infection (UTI)?

From the Guidelines

For an 85-year-old female with a urinary tract infection (UTI), nitrofurantoin for 5 days is the recommended first-line treatment option, as it is effective and has a lower risk of adverse effects compared to other antibiotics, as suggested by the American College of Physicians 1. When choosing an antibiotic for this patient, it is essential to consider the potential risks and benefits of each option.

• Nitrofurantoin is a good choice because it is effective against the most common cause of UTIs, Escherichia coli, and has a lower risk of adverse effects compared to fluoroquinolones.
• Trimethoprim-sulfamethoxazole (TMP-SMX) is also an option, but it may have a higher risk of adverse effects, such as gastrointestinal symptoms and allergic reactions.
• Fluoroquinolones, such as ciprofloxacin, may be considered in cases of suspected resistance or complicated infection, but they carry a higher risk of adverse effects, including tendonitis and neuropathy, especially in elderly patients. It is crucial to consider the patient's kidney function when choosing an antibiotic, as both nitrofurantoin and TMP-SMX require dose adjustments or alternatives if renal function is impaired.
• Before starting antibiotics, obtaining a urine culture is important to confirm the infection and guide therapy if the patient doesn't respond to initial treatment.
• Ensuring adequate hydration and monitoring for potential side effects like dizziness, confusion, or gastrointestinal symptoms is essential in this age group, as elderly patients are more susceptible to adverse drug reactions, as noted in the guidelines from the American College of Physicians 1.

From the FDA Drug Label

The overall eradication rates for pathogens of interest are presented in Table 19. The bacteriologic cure rates overall for levofloxacin and control at the test-of-cure (TOC) visit for the group of all patients with a documented pathogen at baseline (modified intent to treat or mITT) and the group of patients in the mITT population who closely followed the protocol (Microbiologically Evaluable) are summarized in Table 20 Geriatric patients are at increased risk for developing severe tendon disorders including tendon rupture when being treated with a fluoroquinolone such as levofloxacin.

For an 85-year-old female with a urinary tract infection (UTI), levofloxacin may be used, but with caution due to the increased risk of severe tendon disorders, including tendon rupture, in geriatric patients 2, 2. It is essential to weigh the benefits and risks of using levofloxacin in this patient population.

• The patient should be informed of this potential side effect and advised to discontinue levofloxacin and contact their healthcare provider if any symptoms of tendinitis or tendon rupture occur.
• The patient's renal function should be considered, as the risk of toxic reactions to levofloxacin may be greater in patients with impaired renal function 2.
• The dosage of levofloxacin should be selected carefully, and it may be useful to monitor renal function 2.

From the Research

Treatment Options for UTI in an 85-year-old Female

• The recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females includes a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 3.
• For older women, such as the 85-year-old female in question, nitrofurantoin can be an effective treatment option, even with mild or moderate reductions in estimated glomerular filtration rate 4.
• However, it is essential to consider the patient's kidney function and potential resistance patterns when selecting an antibiotic 3, 4.
• Other treatment options, such as oral cephalosporins, fluoroquinolones, and β-lactams, may be considered as second-line options or in cases where the patient has a history of resistance or allergy to first-line agents 3, 5.

Considerations for Antibiotic Resistance

• Resistance to fluoroquinolones, beta-lactams, and trimethoprim-sulfamethoxazole is increasing, making it essential to choose an antibiotic with minimal collateral damage and resistance 3, 6.
• Nitrofurantoin is often a good option, as most uropathogens still display good sensitivity to this antibiotic 6.
• It is crucial to use antibiotics wisely and consider the patient's specific needs and resistance patterns to avoid contributing to the development of antibiotic resistance 3, 6.

Additional Factors to Consider

• The patient's symptoms, medical history, and test results should be taken into account when diagnosing and treating a UTI 6.
• Urine culture is the gold standard for detecting UTI, but asymptomatic bacteriuria is common in older women and should not be treated with antibiotics 6.
• The choice of antibiotic should be based on the pharmacokinetic characteristics of the molecule, as well as the patient's individual needs and potential resistance patterns 5.