From the Guidelines
For treating urinary tract infections (UTIs) in long-term nursing home residents, the best approach typically involves empiric antibiotic therapy with either nitrofurantoin 100mg twice daily for 7 days, trimethoprim-sulfamethoxazole (TMP-SMX) 160/800mg twice daily for 7 days, or cephalexin 500mg four times daily for 7 days, as these options are generally safer and more effective in this population, considering the high risk of comorbidities and polypharmacy 1. When selecting an antibiotic, it is crucial to consider the patient's renal function, as impaired kidney function can affect drug clearance and increase the risk of adverse effects 1.
Key Considerations
- Treatment should be guided by local antibiotic resistance patterns and the patient's medication history, allergies, and renal function.
- Before starting antibiotics, obtain a urine culture to confirm the infection and ensure appropriate antibiotic selection.
- Asymptomatic bacteriuria should not be treated in elderly patients unless they have specific symptoms like fever, new onset confusion, suprapubic pain, or burning urination.
- For prevention, ensure adequate hydration (1.5-2 liters daily unless contraindicated), proper perineal hygiene, and prompt toileting or incontinence care.
- Cranberry products may provide modest benefit for prevention in some patients.
- For recurrent UTIs, consider a urology consultation to rule out structural abnormalities.
Antibiotic Selection
The choice of antibiotic is important because nursing homes often have higher rates of resistant organisms, and elderly patients may have reduced renal function affecting drug clearance and increased risk of adverse effects 1.
- Fluoroquinolones, such as ciprofloxacin, are generally not recommended for empirical treatment of complicated UTIs in patients from urology departments or when patients have used fluoroquinolones in the last 6 months 1.
- Short-course antibiotics (5-7 days) may be effective for complicated UTIs, including pyelonephritis, but more data are needed to confirm their efficacy in men 1.
From the Research
UTI Treatment Options
- The treatment of urinary tract infections (UTIs) is a major healthcare concern, especially in nursing homes where UTIs are the most common type of infection 2.
- Factors such as economic efficiency and emerging resistance are increasingly becoming more important considerations in providing patient care 3.
- The recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females is a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 4.
Antibiotic 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 4.
- Second-line options include oral cephalosporins such as cephalexin or cefixime, fluoroquinolones and β-lactams, such as amoxicillin-clavulanate 4.
Nursing Home Considerations
- Asymptomatic bacteriuria, the most common form of UTI in nursing homes, requires no treatment 2.
- Symptomatic UTI requires treatment, but symptoms may be nonspecific, and complicated UTI is more common in nursing home residents than in other populations 2.
- Interventions to reduce UTIs in nursing home residents include strategies to reduce catheter use or improve catheter care, and general infection prevention strategies such as improving hand hygiene, surveillance, contact precautions, and reducing antibiotics 5.
Effective Treatment Options
- Ciprofloxacin appears to be an effective and safe orally-administrable treatment even for complicated urinary tract infection 6.
- Ciprofloxacin extended release (ER) is a once-daily formulation that has been increasingly used with good clinical success, and combines traditional ciprofloxacin's proven track record of efficacy and safety with favourable pharmacokinetics and convenient once-daily dosing 3.