What is the appropriate treatment for Urinary Tract Infection (UTI) in an older adult with co-morbidities?

From the Guidelines

For treating a urinary tract infection (UTI) in an older adult with comorbidities, a careful approach is needed, prioritizing medications with minimal risk of adverse interactions, such as trimethoprim-sulfamethoxazole or fosfomycin, while avoiding fluoroquinolones due to their potential for serious side effects in this population, as suggested by recent guidelines 1. When selecting an antibiotic, it's crucial to consider the patient's specific comorbidities and potential drug interactions. For instance, patients with kidney disease should avoid nitrofurantoin if their creatinine clearance is below 30 ml/min. Additionally, for those with diabetes, close monitoring of glucose levels is necessary as infections can cause fluctuations. Key considerations in managing UTIs in older adults with comorbidities include:

• Avoiding fluoroquinolones like ciprofloxacin due to the increased risk of tendon rupture and cognitive side effects in older adults 1.
• Ensuring adequate hydration during treatment.
• Considering a shorter course (3-5 days) of antibiotics when appropriate to minimize adverse effects.
• Obtaining a urine culture before starting antibiotics if possible, especially in patients with recurrent UTIs or recent antibiotic exposure.
• Monitoring for medication interactions, particularly in patients taking warfarin, phenytoin, or oral hypoglycemics. After treatment, follow-up is essential to ensure symptom resolution, as older adults may present with atypical symptoms like confusion rather than classic UTI symptoms. This targeted approach helps balance effective treatment while minimizing risks in vulnerable older patients with multiple health conditions, aligning with recommendations for managing urinary infections in frail or comorbid older individuals 1. Recent studies on short-course antibiotics for common infections, including UTIs, support the use of shorter treatment durations for complicated UTIs, which can be beneficial in reducing antibiotic exposure and potential side effects in older adults 1.

From the FDA Drug Label

The usual adult dosage in the treatment of urinary tract infections is 1 sulfamethoxazole and trimethoprim DS tablet every 12 hours for 10 to 14 days For Patients With Impaired Renal Function When renal function is impaired, a reduced dosage should be employed using the following table: Creatinine Clearance (mL/min)Recommended Dosage Regimen Above 30Usual standard regimen 15-301/2 the usual regimen Below 15Use not recommended

The recommended treatment for a UTI in an older adult with co-morbidities is 1 sulfamethoxazole and trimethoprim DS tablet every 12 hours for 10 to 14 days. However, if the patient has impaired renal function, a reduced dosage should be used, with the specific dosage depending on the patient's creatinine clearance 2.

• For patients with a creatinine clearance above 30, the usual standard regimen should be used.
• For patients with a creatinine clearance of 15-30, half the usual regimen should be used.
• For patients with a creatinine clearance below 15, use is not recommended.

From the Research

UTI Treatment in Older Adults with Co-Morbidities

• Older adults with co-morbidities are at a higher risk of developing urinary tract infections (UTIs) due to factors such as immunosenescence, exposure to nosocomial pathogens, and multiple comorbidities 3.
• The diagnosis of UTIs in older adults can be complex due to non-specific symptoms and the presence of comorbidities, making it essential to follow local prescribing guidelines and avoid unnecessary antibiotic use 4, 5.

Antibiotic Treatment

• Antibiotic therapy should not be used routinely for people with asymptomatic bacteriuria, and healthcare professionals should follow local prescribing guidelines when antibiotics are required 4.
• First-line treatments for UTIs include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are <20%) 5.
• Short-course treatment (3 to 6 days) could be sufficient for treating uncomplicated UTIs in elderly women, although more studies on specific commonly prescribed antibiotics are needed 6.

Non-Antimicrobial Options

• Non-antimicrobial options to treat and prevent UTIs include cranberry products, OM-89 Escherichia coli bacterial lysate vaccine, and estrogen therapy in postmenopausal women, although evidence for their efficacy is weak 3.
• A medical device (Utipro Plus®) containing xyloglucan, gelatin, propolis, and extracts of Hibiscus sabdariffa has shown efficacy in controlling and preventing UTIs in patients with uncomplicated and recurrent UTIs 3.

Prevention and Management

• Preventive strategies tailored to post-acute and long-term care (PALTC) populations, such as avoiding the use of indwelling urethral catheters and removing them when no longer necessary, can help reduce the risk of UTIs 4, 7.
• Integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and prescribing clinicians can help optimize UTI management and prevent unnecessary antibiotic use 7.