From the FDA Drug Label
Geriatric patients are at increased risk for developing severe tendon disorders including tendon rupture when being treated with a fluoroquinolone such as Ciprofloxacin Tablets USP, 250 mg, 500 mg and 750 mg. Ciprofloxacin is known to be substantially excreted by the kidney, and the risk of adverse reactions may be greater in patients with impaired renal function. No alteration of dosage is necessary for patients greater than 65 years of age with normal renal function However, since some older individuals experience reduced renal function by virtue of their advanced age, care should be taken in dose selection for elderly patients, and renal function monitoring may be useful in these patients.
The patient is an 82-year-old female with a history of UTIs, dehydrated, and has a GFR of 39.3, indicating impaired renal function. Considering the patient's age and renal function, caution should be taken when prescribing ciprofloxacin.
- The patient's renal function should be monitored.
- The dosage of ciprofloxacin should be adjusted according to the patient's renal function.
- The patient should be informed of the potential side effects of ciprofloxacin, including tendinitis and tendon rupture 1.
From the Research
I recommend treating this 82-year-old long-term care female patient with fosfomycin 3g single dose orally for her urinary tract infection, as it is a recommended first-line empiric therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females, according to the most recent study 2. Given her reduced kidney function with a GFR of 39.3, fosfomycin is a good choice because it has a low risk of nephrotoxicity and does not require dose adjustment in patients with renal impairment. The patient has significant bacteriuria with 100,000 gram-negative rods, likely E. coli, which is commonly responsible for UTIs in elderly patients. Some key points to consider in the management of this patient include:
- The patient's allergies to multiple antibiotics, including trimethoprim-sulfamethoxazole (Bactrim) and penicillin, which limits our options.
- The increasing rates of antibiotic resistance, particularly to fluoroquinolones, which should be used judiciously and reserved for cases where other options are not suitable 3.
- The importance of monitoring for improvement in symptoms within 48-72 hours and considering a follow-up urine culture after treatment completion to ensure resolution.
- The need for the patient to increase fluid intake to address possible dehydration, aiming for at least 1.5-2 liters daily unless contraindicated by other medical conditions. Alternative antibiotics like nitrofurantoin or a fluoroquinolone could be considered if symptoms worsen or don't improve, though the latter carries additional risks in elderly patients 4, 5, 6.