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, and the treatment duration should be 7-14 days, with consideration of shorter courses based on clinical response and culture results, as suggested by the most recent study 1. The choice of antibiotic should be guided by local resistance patterns and the patient's renal function, with fluoroquinolones generally being avoided due to potential resistance and side effects, especially in patients with impaired kidney function 1. Key considerations in the management of UTIs in elderly males include:

• Empirical treatment should be started after obtaining urine and blood cultures, and then tailored based on culture results and antibiotic susceptibility 1.
• Patients can be switched to oral antibiotics when clinically improved and able to tolerate oral medications, with common options including trimethoprim-sulfamethoxazole, amoxicillin-clavulanate, or ciprofloxacin, adjusted for renal function 1.
• Additional interventions may be necessary, such as catheter removal or change, adequate hydration, and management of underlying conditions, especially in patients with complicated UTIs or bacteremia 1.
• Urological evaluation should be considered for recurrent infections to identify anatomical abnormalities or chronic bacterial prostatitis that may require additional treatment 1. It is essential to prioritize antimicrobial stewardship and consider the patient's values and preferences when making treatment decisions, as emphasized in the European Association of Urology guidelines on urological infections 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 may be an effective empiric therapy for most patients with UTIs requiring hospitalization 3.
• The choice of empiric antibiotic therapy should be based on local antibiogram data, taking into account the susceptibility patterns of the most common uropathogens in the area 3, 4.
• For patients with UTIs due to ESBL-producing Enterobacteriaceae, treatment options include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin, as well as parenteral options such as piperacillin-tazobactam, carbapenems, and ceftazidime-avibactam 4.
• In the elderly population, the diagnosis and treatment of UTIs can be challenging due to the presence of comorbidities and the potential for asymptomatic bacteriuria 5, 6.
• A study on the treatment of UTIs in the old and fragile found that cautious choice of antibiotics should be guided by uropathogen identified by culture and sensitivity, and that understanding local antibiotic resistance rates plays a fundamental part in selecting appropriate antimicrobial treatment 6.
• Another study found that in elderly patients with a diagnosis of UTI in primary care, no antibiotics and deferred antibiotics were associated with a significant increase in bloodstream infection and all-cause mortality compared with immediate antibiotics 7.

Treatment Options

• Ceftriaxone may be an effective empiric therapy for most patients with UTIs requiring hospitalization 3.
• Nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin are potential treatment options for UTIs due to ESBL-producing Enterobacteriaceae 4.
• Parenteral options such as piperacillin-tazobactam, carbapenems, and ceftazidime-avibactam may also be considered for UTIs due to ESBL-producing Enterobacteriaceae 4.

Considerations for Elderly Males

• The presence of comorbidities and the potential for asymptomatic bacteriuria should be taken into account when diagnosing and treating UTIs in elderly males 5, 6.
• Understanding local antibiotic resistance rates is crucial in selecting appropriate antimicrobial treatment for UTIs in elderly males 6.
• Early initiation of recommended first-line antibiotics for UTI in the older population is advocated to reduce the risk of bloodstream infection and all-cause mortality 7.