Should oral Cipro (ciprofloxacin) be used to treat hospital-acquired Pseudomonas urinary tract infection (UTI) when susceptible?

From the Guidelines

Oral ciprofloxacin is an appropriate treatment option for hospital-acquired Pseudomonas UTI if the organism is susceptible, with a recommended dose of 500-750 mg orally twice daily for 7-14 days. The treatment duration and dose may vary depending on the severity of the infection and the patient's response to therapy 1. It is essential to ensure a urine culture confirms Pseudomonas and susceptibility to ciprofloxacin before starting treatment, as hospital strains may have resistance. Adequate hydration is crucial during treatment to help flush the urinary tract. Monitoring for improvement of symptoms within 48-72 hours and completing the full course of antibiotics even if symptoms resolve earlier is necessary to prevent recurrence and resistance. Ciprofloxacin works by inhibiting bacterial DNA gyrase, preventing DNA replication in the bacteria. Potential side effects, including tendon inflammation, QT prolongation, and CNS effects, should be considered. If the infection is complicated by bacteremia, renal abscess, or the patient is severely immunocompromised, initial intravenous therapy may be preferable before transitioning to oral therapy. According to the European Association of Urology guidelines, ciprofloxacin should only be used if the local resistance rate is <10% when the entire treatment is given orally, the patient does not require hospitalization, or the patient has anaphylaxis to beta-lactam antimicrobials 1.

Some key points to consider when treating hospital-acquired Pseudomonas UTI with oral ciprofloxacin include:

• Ensuring the organism is susceptible to ciprofloxacin through urine culture and susceptibility testing
• Monitoring for potential side effects and adjusting treatment as needed
• Completing the full course of antibiotics to prevent recurrence and resistance
• Considering alternative treatment options if the infection is complicated or the patient is severely immunocompromised
• Being aware of local resistance rates and adjusting treatment accordingly 1.

It is also important to note that the treatment of hospital-acquired Pseudomonas UTI should be individualized based on the patient's specific needs and circumstances, and that the use of ciprofloxacin should be guided by the most recent and highest-quality evidence available 1.

From the FDA Drug Label

Adult and Pediatric Patients: Complicated Urinary Tract Infections and Pyelonephritis due to Escherichia coli NOTE: Although effective in clinical trials, ciprofloxacin is not a drug of first choice in the pediatric population due to an increased incidence of adverse events compared to controls, including events related to joints and/or surrounding tissues. As with other drugs, some strains of Pseudomonas aeruginosa may develop resistance fairly rapidly during treatment with ciprofloxacin To reduce the development of drug-resistant bacteria and maintain the effectiveness of Ciprofloxacin Tablets USP, 250 mg, 500 mg and 750 mg and other antibacterial drugs, Ciprofloxacin Tablets USP, 250 mg, 500 mg and 750 mg should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria

Treatment of hospital-acquired Pseudomonas UTI with oral ciprofloxacin:

• The FDA drug label for ciprofloxacin does mention Pseudomonas aeruginosa as a pathogen that can be treated with ciprofloxacin, but it does not specifically address hospital-acquired Pseudomonas UTI.
• However, it does state that ciprofloxacin can be used to treat Complicated Urinary Tract Infections.
• Given that the pathogen is susceptible, ciprofloxacin may be considered for treatment, but it is essential to be aware of the potential for resistance development and the need for culture and susceptibility testing.
• It is also crucial to consider the potential risks and benefits, especially in pediatric patients, due to the increased incidence of adverse events 2.

From the Research

Treatment of Hospital-Acquired Pseudomonas UTI

• The treatment of hospital-acquired Pseudomonas UTI should be guided by antimicrobial susceptibility testing and local epidemiology 3, 4.
• For susceptible Pseudomonas aeruginosa strains, fluoroquinolones such as ciprofloxacin may be considered as a treatment option 3, 5.
• However, the use of ciprofloxacin should be cautious due to the potential for resistance development and the high intrinsic antibiotic resistance of P. aeruginosa 6, 4.
• Other treatment options for Pseudomonas UTI include ceftazidime, cefepime, piperacillin-tazobactam, carbapenems, and ceftolozane-tazobactam 3, 5, 4.

Considerations for Empiric Treatment

• Empiric treatment with anti-Pseudomonal agents may be justified in patients with hospital-acquired UTI, particularly those who have recently received antibiotics 7.
• However, the choice of empiric treatment should be based on local epidemiology and the presence of risk factors for multidrug-resistant infections 7, 4.
• The use of newer antibiotics such as ceftazidime-avibactam and ceftolozane-tazobactam should be reserved for cases where the susceptibility pattern is known or suspected to be resistant to other agents 4.

Antibiotic Resistance and Tolerance

• Pseudomonas aeruginosa has a high intrinsic antibiotic resistance and can develop new resistances during antibiotic treatment 6, 4.
• The antibiotic tolerance of P. aeruginosa can be enhanced by urinary tract conditions such as nutrient composition, biofilm growth, and oxygen concentration 6.
• The use of antibiotics should be guided by antimicrobial susceptibility testing and the potential for resistance development should be considered 3, 4.