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J Am Geriatr Soc. 2018 Dec 24. doi: 10.1111/jgs.15726. [Epub ahead of print]

The IOU Consensus Recommendations for Empirical Therapy of Cystitis in Nursing Home Residents.

Author information

Division of Geriatric Medicine, Department of Medicine (Geriatrics), University of Pittsburgh, Pittsburgh, Pennsylvania.
Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania.
Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System (VAPHS), Pittsburgh, Pennsylvania.
Center for Health Equity Research and Promotion (CHERP), VAPHS, Pittsburgh, Pennsylvania.
Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
Divisions of Internal Medicine and Geriatric Medicine, University of Wisconsin, Madison, Wisconsin.
Infectious Disease, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin.
William S. Middleton Veterans Administration Medical Center, Madison, Wisconsin.
Infection Prevention Consultant, Saylorsburg, Pennsylvania.
Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania.
AMDA, The Society of Post-Acute and Long-Term Care Medicine, Columbia, Maryland.



To establish consensus recommendations for empirical treatment of uncomplicated cystitis with anti-infectives in noncatheterized older nursing home residents to be implemented in the Improving Outcomes of UTI Management in Long-Term Care Project (IOU) funded by the Agency for Healthcare Research and Quality.


Two-round modified Delphi survey.


Expert panel of 19 clinical pharmacists.


Comprehensive literature search and development/review/edit of draft survey by the investigative group (one geriatric clinical pharmacist, two geriatric medicine physicians, and one infectious disease physician). The expert panel members rated their agreement with each of 31 recommendations for drugs of choice, dosing medications at various levels of renal function, drug-drug interactions to avoid, and duration of therapy by sex on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Consensus agreement was defined as a lower 95% confidence limit of 4.0 or higher for the recommendation-specific mean score.


The response rate was 95% for the first round, and three recommendations achieved consensus (dosing for nitrofurantoin and trimethoprim/sulfamethoxazole in those without chronic kidney disease, and drug-drug interaction between trimethoprim/sulfamethoxazole and warfarin). In the second round, 90% responded and reached consensus on an additional eight recommendations (two for nitrofurantoin or trimethoprim/sulfamethoxazole as initial drugs of choice, three for dosing ciprofloxacin, nitrofurantoin, and trimethoprim/sulfamethoxazole at various levels of chronic kidney disease, and three drug-drug interactions to avoid: trimethoprim/sulfamethoxazole with phenytoin and ciprofloxacin with theophylline or with tizanidine).


An expert panel of clinical pharmacists was able to reach consensus on a set of recommendations for the empirical treatment of cystitis with oral anti-infective medications in older nursing home residents. The recommendations were incorporated into a treatment algorithm for uncomplicated cystitis in noncatheterized nursing home residents and used in educational materials for health professionals in an ongoing controlled intervention study.


aged; antibacterial agents; cystitis; nursing homes; urinary tract infection


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