What is the recommended treatment for a 60-year-old woman with urinary tract infection symptoms, anemia (low hemoglobin) and leukocytosis (high white blood cell count)?

Treatment Approach for UTI in a 60-Year-Old Woman with Anemia and Leukocytosis

In a 60-year-old woman presenting with UTI symptoms, low hemoglobin, and elevated white blood cell count, you should immediately obtain a urine culture before starting empiric antibiotics, assess for systemic signs of complicated infection or urosepsis, and initiate first-line therapy with nitrofurantoin 100 mg twice daily for 5–7 days while investigating the cause of anemia. 1, 2

Immediate Diagnostic Workup

Confirm UTI Diagnosis

• Both pyuria (≥10 WBC/HPF or positive leukocyte esterase) AND acute urinary symptoms (dysuria, frequency, urgency, fever >38.3°C, or gross hematuria) must be present to justify antibiotic treatment. 1, 2
• The combination of leukocyte esterase and nitrite positivity achieves 93% sensitivity and 96% specificity for culture-positive UTI. 2

Assess for Complicated UTI or Urosepsis

• Leukocytosis (WBC >12,000/μL) combined with UTI symptoms significantly increases the likelihood of bacteremia and urosepsis. 3
• Check for systemic signs: fever >38.3°C, rigors, hypotension (systolic BP <100 mmHg), altered mental status, or tachycardia. 1, 3
• If urosepsis is suspected, obtain paired blood cultures immediately before starting antibiotics, and consider a Gram stain of uncentrifuged urine for rapid pathogen identification (sensitivity 91–96%, specificity 96%). 1, 2

Mandatory Urine Culture

• Always obtain urine culture with susceptibility testing before initiating antibiotics in women ≥60 years, as this population has higher rates of resistant organisms and atypical presentations. 1, 4
• Use proper collection technique: midstream clean-catch or in-and-out catheterization if contamination is suspected. 1, 2

Investigate Anemia

• The combination of UTI symptoms with anemia warrants evaluation for:
  • Gross hematuria (which may cause acute blood loss). 1, 2
  • Chronic kidney disease (anemia of chronic disease). 5
  • Underlying malignancy (particularly in women >35 years with hematuria). 2
• Order complete blood count with differential, reticulocyte count, iron studies, and renal function tests (creatinine, eGFR). 5

Empiric Antibiotic Selection

First-Line Therapy for Uncomplicated Cystitis

• Nitrofurantoin 100 mg orally twice daily for 5–7 days is the preferred first-line agent because resistance rates remain <5%, urinary concentrations are high, and gut flora disruption is minimal. 1, 2, 4
• Alternative first-line options:
  • Fosfomycin 3 g single oral dose (excellent for adherence concerns and any degree of renal impairment). 1, 2, 5
  • Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days only if local E. coli resistance is <20% and no recent exposure to this drug. 1, 2, 6, 4

Avoid Fluoroquinolones as First-Line

• Reserve ciprofloxacin and levofloxacin for second-line use due to rising resistance, serious adverse effects (tendon rupture, peripheral neuropathy, QT prolongation), and substantial microbiome disruption. 1, 2, 5
• Use fluoroquinolones only when first-line agents are contraindicated or local resistance precludes other options. 1, 5

Treatment for Complicated UTI or Pyelonephritis

• If systemic signs are present (fever, rigors, hypotension, nausea/vomiting, flank pain), treat as complicated UTI or pyelonephritis with 7–14 days of therapy. 1, 3
• Empiric options for complicated UTI:
  • Fluoroquinolone (ciprofloxacin 500 mg twice daily or levofloxacin 750 mg once daily) for 7–10 days if local resistance <10%. 1, 5
  • Intravenous third-generation cephalosporin (ceftriaxone 1–2 g daily) or amoxicillin plus aminoglycoside for severe cases. 1

Special Considerations in This Patient

Renal Function Assessment

• Calculate creatinine clearance using the Cockcroft-Gault equation to guide antibiotic dosing, as renal function declines by approximately 40% by age 70. 5
• Avoid nitrofurantoin if creatinine clearance <30 mL/min due to inadequate urinary concentrations and increased pulmonary toxicity risk. 2, 5
• Fosfomycin requires no dose adjustment regardless of renal function, making it ideal for elderly patients with renal impairment. 5

Anemia Management

• Do not delay antibiotic therapy while investigating anemia, but address both issues concurrently. 1
• If gross hematuria is present and persists beyond 6 weeks after treatment, refer for urologic evaluation (CT urography, cystoscopy) to exclude malignancy or urolithiasis. 2

Risk Factors for Bacteremia

• Diabetes mellitus, ureteral stones, hydronephrosis, nausea/vomiting, and leukocytosis are significantly associated with urosepsis in UTI patients. 3
• If any of these are present, maintain a high index of suspicion for bacteremia and consider imaging (renal ultrasound or CT) to rule out obstruction or abscess. 1, 3

Follow-Up and Monitoring

Clinical Reassessment

• Reassess clinical response within 48–72 hours. If symptoms persist or worsen, modify antibiotics based on culture susceptibility and consider imaging. 1, 2
• No routine post-treatment urinalysis or culture is needed if symptoms resolve completely. 2

Culture-Guided Therapy

• Adjust antibiotics based on susceptibility results once culture data are available, especially given the high prevalence of resistant organisms in older adults. 1, 4
• If symptoms recur within 2 weeks, assume resistance to the initial antibiotic and prescribe a 7-day course of a different agent. 2

Anemia Follow-Up

• Recheck hemoglobin after UTI treatment to determine if anemia was acute (from hematuria) or chronic (requiring further investigation). 5

Critical Pitfalls to Avoid

• Do not treat based on pyuria alone without urinary symptoms—asymptomatic bacteriuria occurs in 15–50% of older women and should never be treated. 1, 2, 5
• Do not assume leukocytosis is solely due to UTI—consider alternative sources of infection or systemic illness. 3
• Do not use amoxicillin or ampicillin empirically due to very high worldwide resistance rates. 5
• Do not prescribe a 3-day course of nitrofurantoin—the minimum effective duration is 5 days to avoid treatment failure. 2
• Do not ignore persistent hematuria after treatment—this requires urologic evaluation to exclude malignancy, especially in women >35 years. 2