What are the alternative treatment options for an 89-year-old female patient with Escherichia coli (E. coli) urinary tract infection (UTI) who has difficulty swallowing pills and cannot afford compounded Macrobid (Nitrofurantoin), specifically seeking medications with crushable formulations?

From the Guidelines

For treating an E. coli UTI in an 89-year-old female who cannot swallow pills and finds compounded nitrofurantoin (Macrobid) too expensive, trimethoprim-sulfamethoxazole (Bactrim) is the most appropriate alternative option with crushable pills, dosed at 160/800mg (one double-strength tablet) twice daily for 3-5 days, as recommended by the European Association of Urology guidelines on urological infections 1. When considering alternative options, it's essential to prioritize the patient's ability to tolerate the medication, local resistance patterns, and potential side effects.

• Trimethoprim-sulfamethoxazole (Bactrim) tablets can be crushed and mixed with soft food like applesauce or pudding, making it a suitable option for patients who have difficulty swallowing pills.
• Amoxicillin-clavulanate (Augmentin) tablets are also crushable, with a typical dose of 500/125mg twice daily for 5-7 days, but may have a higher risk of adverse effects in elderly patients.
• Cephalexin (Keflex) capsules can be opened and the contents mixed with food, dosed at 500mg four times daily for 7 days, but may have inferior efficacy compared to other available therapies, as noted in the international clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women 1. The choice between these options should consider local resistance patterns, patient allergies, and renal function, which is particularly important in elderly patients, as emphasized in the European Association of Urology guidelines on urological infections 1.
• It's crucial to note that the European Association of Urology guidelines on urological infections 1 provide the most recent and highest quality evidence for treating uncomplicated cystitis, and should be prioritized when making treatment decisions.
• The guidelines recommend considering the spectrum and susceptibility patterns of the aetiological pathogens, efficacy for the particular indication in clinical studies, tolerability and adverse reactions, adverse ecological effects, and costs and/or availability when choosing an antimicrobial therapy.
• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients, but for women whose symptoms do not resolve by the end of treatment, and for those whose symptoms resolve but recur within 2 weeks, a urine culture and antimicrobial susceptibility testing should be performed, as recommended by the European Association of Urology guidelines on urological infections 1.

From the FDA Drug Label

Take Ciprofloxacin Tablets USP exactly as prescribed by your healthcare provider Take Ciprofloxacin Tablets USP in the morning and evening at about the same time each day. Swallow the tablet whole. Do not split, crush or chew the tablet. Tell your healthcare provider if you can not swallow the tablet whole.

The patient cannot swallow pills, and the label instructs not to crush the tablet. Ciprofloxacin tablets are not suitable for this patient.

• Other options with crushable pills should be considered.
• The FDA label does not provide information on alternative formulations of ciprofloxacin that may be suitable for patients who cannot swallow pills 2.

From the Research

Treatment Options for E. coli UTI in an 89-year-old Female

The patient has a urinary tract infection (UTI) caused by E. coli and is unable to swallow pills, with compounded Macrobid being too expensive. Other options with crushable pills are available.

• Nitrofurantoin: This antibiotic has been shown to be effective against E. coli UTIs, with high susceptibility rates reported in several studies 3, 4, 5. Nitrofurantoin is available in a crushable form, making it a potential option for the patient.
• Amoxicillin/Clavulanate: This combination antibiotic has also been shown to be effective against E. coli UTIs, with high susceptibility rates reported in several studies 3, 6, 7. Amoxicillin/Clavulanate is available in a crushable form, making it another potential option for the patient.
• Cefixime: This cephalosporin antibiotic has been shown to be effective against E. coli UTIs, particularly when combined with amoxicillin/clavulanate 6. Cefixime is available in a crushable form, making it a potential option for the patient.

Considerations for Treatment

When selecting a treatment option, it is essential to consider the patient's individual needs and the susceptibility patterns of the E. coli isolate. The studies cited above provide evidence for the effectiveness of various antibiotics against E. coli UTIs, but the choice of treatment should be guided by the patient's specific circumstances and the results of antimicrobial susceptibility testing 3, 4, 7.