What is the initial treatment for a 62-year-old female presenting with symptoms of a Urinary Tract Infection (UTI)?

Initial Evaluation and Treatment of UTI in a 62-Year-Old Female

For a 62-year-old woman with UTI symptoms, obtain a urinalysis and urine culture before initiating empiric antibiotic therapy with nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin for 5-7 days, based on your local antibiogram. 1

What to Ask (History)

Assess specific urinary symptoms:

• Dysuria (burning with urination) - this is the most specific symptom for UTI with >90% accuracy 1
• Urinary frequency and urgency 1
• Nocturia (nighttime urination) 1
• Suprapubic pain 2
• Hematuria (blood in urine) 1
• New or worsening incontinence 1

Exclude vaginal symptoms that suggest alternative diagnoses:

• Vaginal discharge or irritation (suggests vaginitis rather than UTI) 1, 2

Obtain UTI history:

• Frequency of prior UTIs and whether cultures were documented 1
• Previous antimicrobial usage and any documented resistant organisms 1
• Recent antibiotic exposure (increases resistance risk) 3

Screen for complicated UTI risk factors:

• Diabetes, immunosuppression, or structural urinary tract abnormalities 1
• Recent urologic procedures or instrumentation 4
• Presence of urinary catheter 4

What to Do (Physical Examination and Testing)

Perform focused physical examination:

• Abdominal examination for suprapubic tenderness 1
• Pelvic examination to assess for vaginal atrophy and pelvic organ prolapse 1
• Assess for costovertebral angle tenderness (suggests pyelonephritis, not simple cystitis) 5

Obtain diagnostic testing:

• Urinalysis and urine culture with sensitivity testing before initiating antibiotics 1
• This is particularly important in women over 65 years to guide antibiotic selection 2
• If initial specimen is contaminated, obtain a catheterized specimen 1

Do NOT routinely perform:

• Cystoscopy or upper tract imaging for initial UTI presentation 1
• Surveillance urine testing in asymptomatic patients 1

Initial Antibiotic Treatment

First-line empiric therapy options (choose based on local antibiogram): 1

• Nitrofurantoin for 5 days 1, 2

  • Preferred agent with lowest treatment failure risk 6
  • Less collateral damage to normal flora 1

• Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 3 days 1, 2

  • Only use if local resistance is <20% 5, 3
  • Higher treatment failure risk than nitrofurantoin 6
  • Avoid if recent TMP-SMX exposure 3

• Fosfomycin as single 3-gram dose 1, 2

  • Alternative first-line option 3, 2

Treatment duration:

• Generally no longer than 7 days for acute cystitis 1
• Shorter courses (3-5 days) are appropriate for uncomplicated cases 1, 2

Consider patient-initiated treatment:

• Select patients with recurrent UTIs may self-start antibiotics while awaiting culture results 1

Second-Line Options (if first-line agents contraindicated)

• Fluoroquinolones (ciprofloxacin) should be avoided as first-line due to resistance concerns and serious adverse effects 5, 3
• Oral cephalosporins (cephalexin, cefixime) 3
• Beta-lactams such as amoxicillin-clavulanate 3

Critical Pitfalls to Avoid

Do not treat asymptomatic bacteriuria:

• Even if urine culture is positive, treatment without symptoms increases antibiotic resistance 1
• Exception: pregnant women and patients undergoing invasive urologic procedures 1

Avoid broad-spectrum antibiotics unnecessarily:

• Use narrow-spectrum agents to minimize collateral damage and resistance development 1
• Reserve fluoroquinolones and cephalosporins for resistant organisms 5, 3

Do not use single-dose antibiotic therapy:

• Associated with higher bacteriological persistence compared to 3-7 day courses 1

Adjust therapy based on culture results:

• If symptoms persist after 48-72 hours, reassess and adjust antibiotics based on sensitivity testing 5
• Consider imaging if no improvement to rule out complications 5

Special Considerations for Age 65+

Older women require the same first-line antibiotics and durations as younger adults 2

• However, culture with susceptibility testing is more important to guide therapy 2
• Symptoms may be less clear in older adults 1
• Increased risk of tendon disorders with fluoroquinolones, especially if on corticosteroids 7