What is the appropriate treatment for urinary tract infections (UTI) in elderly male inpatients?

From the Guidelines

Inpatient treatment of UTIs in elderly males should prioritize empiric broad-spectrum antibiotics, with a treatment duration of 7-14 days, and careful consideration of underlying urologic abnormalities, as recommended by the European Association of Urology guidelines 1. Inpatient treatment of UTIs in elderly males typically involves empiric broad-spectrum antibiotics initially, followed by targeted therapy based on culture results. For empiric treatment, intravenous options include third-generation cephalosporins (ceftriaxone 1-2g IV q24h) or piperacillin-tazobactam (3.375g IV q6h) if more resistant organisms are suspected, as fluoroquinolones are generally inappropriate for this population due to potential drug interactions and contraindications such as impaired kidney function 1. Some key points to consider in the treatment of UTIs in elderly males include:

• Treatment duration is generally 7-14 days, with longer courses for complicated infections, although short-duration courses (5-7 days) may be effective for complicated UTIs, as shown in some studies 1.
• Elderly males often have complicated UTIs due to prostatic enlargement, urinary retention, or catheter use, requiring careful consideration of these factors.
• Supportive care includes adequate hydration, monitoring of renal function, and management of urinary retention if present.
• Once the patient improves clinically and culture results are available, therapy should be narrowed to the most appropriate antibiotic based on susceptibility testing.
• Transition to oral therapy can occur when the patient is clinically stable, typically after 48-72 hours of IV treatment.
• Common oral options include trimethoprim-sulfamethoxazole (160/800mg q12h), or amoxicillin-clavulanate (875/125mg q12h), depending on susceptibility, as ciprofloxacin and other fluoroquinolones should be avoided for empirical treatment of complicated UTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months 1.
• Addressing underlying urologic abnormalities is crucial to prevent recurrence, which may include urologic consultation for prostatic issues or catheter management.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION The recommended adult and pediatric dosages and routes of administration are outlined in the following table 10. Mild to Moderate Uncomplicated or Complicated Urinary Tract Infections, including pyelonephritis, due to E. coli, K. pneumoniae, or P. mirabilis† 0. 5 to 1 gIV/IM¶ Every 12 hours 7 to 10 Severe Uncomplicated or Complicated Urinary Tract Infections, including pyelonephritis, due to E. coli or K. pneumoniae† 2 g IV Every 12 hours 10

For inpatient UTI treatment in elderly males, the recommended dose of cefepime (IV) is:

• Mild to Moderate Uncomplicated or Complicated Urinary Tract Infections: 0.5 to 1 g IV/IM every 12 hours for 7 to 10 days
• Severe Uncomplicated or Complicated Urinary Tract Infections: 2 g IV every 12 hours for 10 days It is essential to note that the dose should be adjusted in patients with renal impairment. The Cockcroft and Gault equation can be used to estimate creatinine clearance in patients with renal impairment 2.

For ceftriaxone (IV), the drug label does not provide specific dosage recommendations for inpatient UTI treatment in elderly males. However, it states that dosage adjustments are not necessary for geriatric patients with ceftriaxone dosages up to 2 grams per day, provided there is no severe renal and hepatic impairment 3.

Key considerations for inpatient UTI treatment in elderly males include:

• Renal function: Adjust the dose according to the patient's renal function
• Type and severity of infection: Choose the appropriate dose based on the type and severity of the infection
• Concurrent medications and medical conditions: Consider potential interactions and contraindications with other medications and medical conditions.

From the Research

Inpatient UTI Treatment in Elderly Males

• The diagnosis of symptomatic UTI in elderly males can be challenging, and routine screening and antimicrobial therapy for asymptomatic bacteriuria should not be recommended 4.
• A cautious choice of antibiotics should be guided by uropathogen identified by culture and sensitivity, and understanding local antibiotic resistance rates plays a fundamental part in selecting appropriate antimicrobial treatment 4.
• Optimal management of comorbidities such as diabetes mellitus, adequate treatment of urinary incontinence, and judicious use of urinary catheter is essential to reduce the development of UTI 4.
• In elderly patients with a diagnosis of UTI, no antibiotics and deferred antibiotics were associated with a significant increase in bloodstream infection and all cause mortality compared with immediate antibiotics 5.
• A 3-day course of ceftriaxone was found to be as efficacious as longer antibiotic courses for inpatient treatment of uncomplicated urinary tract infection 6.
• Community nurses are well placed to assess and manage UTIs in older people, implementing correct treatment and resolution, owing to the close relationships they cultivate with service users 7.

Antibiotic Management

• The choice of antibiotics should be guided by the results of culture and sensitivity testing, and the potential impact of associated adverse effects, particularly those with effects on cognitive function, should be considered 4.
• Intravesical antimicrobial instillation seems to be a relatively safe and effective method for the prophylaxis and treatment of recurrent UTIs, especially in the short term 8.
• Early initiation of recommended first-line antibiotics for UTI in the older population is advocated, particularly in men older than 85 years who are at higher risk for bloodstream infection and 60-day all-cause mortality 5.

Special Considerations

• The management of UTIs in elderly males may differ from that in females, and community nurses should be aware of these differences when assessing and managing UTIs in older people 7.
• The use of urinary catheters and the management of recurrent infections should also be taken into account when developing a treatment plan for UTIs in elderly males 4, 7.