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 begin with parenteral antibiotics, such as ceftriaxone 1-2g IV daily or piperacillin-tazobactam 3.375g IV every 6 hours, due to the high risk of complications and the need for broad-spectrum coverage, as recommended by the European Association of Urology guidelines 1. The choice of antibiotic should be guided by local resistance patterns and the patient's renal function, with fluoroquinolones generally avoided due to high resistance rates and potential side effects 1. Treatment should be tailored based on culture results and antibiotic susceptibility testing, with a typical duration of 7-14 days, and longer courses for complicated infections or prostatitis involvement 1. Supportive care includes adequate hydration, bladder management if retention is present, and prompt removal of urinary catheters when possible, as well as consideration of urological evaluation before discharge to address any anatomical abnormalities or obstructions contributing to infection 1. Patients can be switched to oral antibiotics, such as trimethoprim-sulfamethoxazole or amoxicillin-clavulanate, when clinically improved and able to tolerate oral medications, with dosing adjusted for renal function 1. It is essential to consider the patient's comorbidities, polypharmacy, and potential adverse events when selecting antibiotics, as well as the importance of antimicrobial stewardship to combat the rising threat of antimicrobial resistance 1.

Some key points to consider in the treatment of UTIs in elderly males include:

• The importance of a thorough medical history and physical examination to guide treatment decisions 1
• The need for careful consideration of complicating factors, such as prostatic enlargement, urinary retention, or catheter use 1
• The role of antimicrobial stewardship in selecting antibiotics and minimizing the risk of resistance 1
• The importance of adjusting antibiotic dosing for renal function and considering potential drug interactions 1

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 Patients with Renal Impairment In patients with creatinine clearance less than or equal to 60 mL/min, the dose of cefepime for injection should be adjusted to compensate for the slower rate of renal elimination Table 11: Recommended Dosing Schedule for Cefepime for Injection in Adult Patients (Normal Renal Function, Renal Impairment, and Hemodialysis)

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

• Mild to Moderate Uncomplicated or Complicated Urinary Tract Infections: 0.5 to 1 g IV 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 adjust the dose in patients with renal impairment using the recommended dosing schedule in Table 11, considering the patient's creatinine clearance. The dose should be adjusted to compensate for the slower rate of renal elimination in patients with creatinine clearance less than or equal to 60 mL/min 2.

From the Research

Inpatient UTI Treatment in Elderly Males

• The treatment of urinary tract infections (UTIs) in elderly males, particularly those requiring hospitalization, is a complex issue due to the increasing prevalence of antibiotic-resistant bacteria 3, 4.
• A retrospective review of ceftriaxone versus levofloxacin for the treatment of E. coli UTIs found that ceftriaxone seems to be an effective empiric therapy for most patients, with a shorter median time to susceptible therapy and lower median hospital cost compared to levofloxacin 3.
• The choice of empiric antibiotic therapy should be based on local antibiogram data, taking into account the patient's specific risk factors and the susceptibility patterns of the uropathogens involved 3, 5.
• For patients with UTIs requiring hospitalization, parenteral treatment options such as piperacillin-tazobactam, carbapenems, and ceftazidime-avibactam may be considered, depending on the severity of the infection and the patient's underlying health status 4.
• In elderly patients, the diagnosis and treatment of UTIs can be challenging due to the presence of comorbidities and the potential for asymptomatic bacteriuria 6, 7.
• A population-based cohort study found that delayed or no antibiotic treatment for UTIs in elderly patients was associated with an increased risk of bloodstream infections and all-cause mortality, highlighting the importance of prompt and appropriate antibiotic therapy in this population 7.

Considerations for Antibiotic Therapy

• The selection of antibiotics should be guided by the results of urine culture and sensitivity testing, as well as local antibiotic resistance rates 4, 6.
• The potential for adverse effects, particularly those affecting cognitive function, should be considered when choosing antibiotics for elderly patients 6.
• The use of narrow-spectrum antibiotics with minimal collateral damage is recommended to prevent the development of resistance and reduce the risk of complications 5.