From the Guidelines
For recurrent symptomatic UTIs in a 91-year-old patient, I strongly recommend a comprehensive approach including both treatment and prevention strategies, prioritizing the use of vaginal oestrogen replacement in postmenopausal women to prevent recurrent UTI, as supported by the European Association of Urology guidelines 1.
Treatment Strategies
For acute UTI episodes, a 3-5 day course of antibiotics such as nitrofurantoin 100mg twice daily (if renal function allows), trimethoprim-sulfamethoxazole 160/800mg twice daily, or fosfomycin 3g single dose is appropriate, guided by local resistance patterns and previous culture results 1.
Prevention Strategies
Consider daily cranberry supplements (500-1000mg), although the evidence is weak and contradictory 1, adequate hydration of 1.5-2L daily unless contraindicated, and proper perineal hygiene including front-to-back wiping.
- In postmenopausal women, vaginal oestrogen replacement is strongly recommended to prevent recurrent UTI 1.
- For patients with frequent recurrences (3+ UTIs per year), antibiotic prophylaxis may be warranted, such as nitrofurantoin 50-100mg daily at bedtime or trimethoprim-sulfamethoxazole 40/200mg daily for 3-6 months 1.
Special Considerations
Regular reassessment is essential to monitor efficacy and adjust the regimen as needed, while minimizing antibiotic exposure to prevent resistance development 1. In older patients, it is crucial to carefully consider comorbidities, polypharmacy, and the risk of potential adverse events when selecting treatment and prevention strategies 1.
From the Research
Treatment Options for Recurrent Symptomatic UTI
- The treatment of urinary tract infections (UTIs) caused by antibiotic-resistant Gram-negative bacteria is a growing concern due to limited treatment options 2.
- For acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females, the recommended first-line empiric antibiotic therapy includes a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 2.
- Second-line options include oral cephalosporins such as cephalexin or cefixime, fluoroquinolones, and β-lactams, such as amoxicillin-clavulanate 2.
Antibiotic Susceptibility and Resistance
- High rates of resistance for trimethoprim-sulfamethoxazole and ciprofloxacin preclude their use as empiric treatment of UTIs in several communities, particularly if patients who were recently exposed to them or in patients who are at risk of infections with extended-spectrum β-lactamases (ESBLs)-producing Enterobacteriales 2.
- Amoxicillin/clavulanate and nitrofurantoin are appropriate first-line options for empiric treatment of symptomatic cystitis in long-term care facilities, with sulfamethoxazole/trimethoprim as an alternative 3.
Pharmacological Properties of Oral Antibiotics
- The choice of agent for treating uncomplicated UTIs should be based on the pharmacokinetic characteristics of the molecule so that clinical benefit is optimized and the risk of antibacterial resistance is minimized 4.
- Nitrofurantoin modified release has been shown to be effective in the treatment of uncomplicated urinary tract infection in general practice, with a clinical cure rate of 87.2% and a bacteriological cure rate of 82.3% 5.
Considerations for Older Adults
- For a 91-year-old patient with recurrent symptomatic UTI, it is essential to consider the patient's medical history, antibiotic susceptibility, and potential side effects when selecting an antibiotic regimen 3.
- Nitrofurantoin and amoxicillin/clavulanate may be suitable options for older adults with UTIs, given their efficacy and safety profiles 3, 5.