What is the treatment for urinary tract infection (UTI) in an inpatient with confusion?

From the Guidelines

Inpatient treatment for a urinary tract infection (UTI) with confusion typically requires empiric broad-spectrum antibiotics, such as intravenous ceftriaxone 1-2g daily or piperacillin-tazobactam 3.375g every 6 hours, while awaiting culture results, as recommended by the European Association of Urology guidelines 1. For elderly patients with confusion (which may indicate UTI-associated delirium), it is crucial to start treatment promptly.

• The choice of antibiotic should be based on local resistance patterns and patient-specific factors, such as allergy history and renal function.
• Treatment should continue for 7-14 days depending on clinical response, with transition to oral antibiotics once the patient improves clinically and confusion resolves, as supported by a study on short-course antibiotics for common infections, including UTIs 1.
• Supportive care is essential, including IV fluids for hydration, antipyretics for fever, and careful monitoring of vital signs and mental status.
• The confusion results from inflammatory cytokines crossing the blood-brain barrier or from electrolyte imbalances caused by the infection, and elderly patients are particularly susceptible to this presentation.
• Once culture results return, antibiotics should be narrowed based on susceptibility, and confusion-reduction strategies like frequent reorientation, maintaining day-night cycles, and avoiding unnecessary medications that could worsen confusion should be implemented.
• It is also important to manage any urological abnormality and/or underlying complicating factors, as recommended by the European Association of Urology guidelines 1.

From the FDA Drug Label

Adult Patients: Urinary Tract Infections caused by Escherichia coli (including cases with secondary bacteremia), Klebsiella pneumoniae subspecies pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, Providencia rettgeri, Morganella morganii, Citrobacter diversus, Citrobacter freundii, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus epidermidis, Staphylococcus saprophyticus, or Enterococcus faecalis.

The patient's confusion is not directly addressed in the provided drug labels as a factor in the treatment of Urinary Tract Infections (UTIs) with ciprofloxacin. However, ciprofloxacin is indicated for the treatment of UTIs in adult patients caused by susceptible strains of certain microorganisms.

• The decision to use ciprofloxacin in a patient with confusion should be based on a thorough evaluation of the patient's condition and the potential benefits and risks of treatment.
• It is essential to consider the patient's overall health status, including any underlying conditions that may be contributing to the confusion, as well as the potential for drug interactions or adverse effects.
• The patient's confusion may be a sign of a more severe infection, such as sepsis, which would require prompt and aggressive treatment.
• In the absence of explicit guidance in the drug label, a conservative clinical decision would be to consult with a specialist or consider alternative treatment options that may be more appropriate for the patient's specific condition 2.

From the Research

UTI Treatment in Inpatient with Confusion

• The treatment of urinary tract infections (UTIs) in inpatients with confusion is a complex issue, and several studies have investigated this topic 3, 4.
• A health record review of 499 adults aged ≥65 presenting to academic emergency departments (EDs) with confusion found that 64.9% received urine tests, 11.4% were diagnosed with UTI, and 35.2% were prescribed antibiotics 3.
• Another study found that confusion was strongly associated with antibiotic prescribing due to suspected UTIs in nursing homes, with an odds ratio of 8.9 (95% CI = 3.1-26, P < .001) 4.
• The choice of antibiotic therapy for UTIs is crucial, and several options are available, including piperacillin/tazobactam, carbapenems, and cefepime/enmetazobactam 5, 6, 7.
• A randomized clinical trial found that cefepime/enmetazobactam was noninferior to piperacillin/tazobactam for the treatment of complicated UTIs or acute pyelonephritis, with a primary outcome of clinical cure and microbiological eradication 7.
• Empirical antibiotic therapy should be instigated within the first hour after diagnosis, and urine cultures and blood cultures should be performed before antibiotic treatment 5.

Antibiotic Therapy Options

• Piperacillin/tazobactam has been shown to be effective in the treatment of complicated UTIs, with a clinical response rate of 86% and a bacteriological response rate of 73% 6.
• Cefepime/enmetazobactam has been found to be noninferior to piperacillin/tazobactam, with a primary outcome of clinical cure and microbiological eradication 7.
• Carbapenems are also an option for the treatment of UTIs, particularly in cases where extended-spectrum beta-lactamase (ESBL) producing bacteria are suspected 5.

Considerations for Inpatients with Confusion

• Inpatients with confusion should be carefully evaluated for UTIs, and antibiotic therapy should be tailored to the individual patient's needs 3, 4.
• The presence of confusion should not be the sole criterion for antibiotic treatment, and other factors such as urinary symptoms, fever, and laboratory results should be taken into account 3, 4.