From the Guidelines
For chronic bacteriuria with ESBL-producing E. coli, treatment is generally recommended only if the patient is symptomatic or in specific situations like pregnancy or before urologic procedures. If treatment is necessary, fosfomycin (3g oral single dose, potentially repeated every 3 days for 1-2 weeks in complicated cases) is often effective, as shown in recent studies 1. Alternative options include nitrofurantoin (100mg twice daily for 5-7 days) if the organism is susceptible, or carbapenems like ertapenem (1g IV/IM daily) for more severe infections. Asymptomatic bacteriuria in most adults should not be treated as it may lead to antibiotic resistance without clinical benefit.
Before starting treatment, confirm susceptibility through urine culture and sensitivity testing since ESBL producers are resistant to many common antibiotics including cephalosporins and penicillins 1. Address underlying factors such as catheter removal if present, proper hydration, and good perineal hygiene. ESBL enzymes hydrolyze the beta-lactam ring in many antibiotics, rendering them ineffective, which is why targeted therapy based on susceptibility testing is crucial for successful treatment.
Some key points to consider in the management of chronic bacteriuria with ESBL-producing E. coli include:
- Treatment duration: 7 to 14 days, depending on the severity of the infection and the patient's response to treatment 1
- Choice of antibiotic: fosfomycin, nitrofurantoin, or carbapenems, depending on the susceptibility of the organism and the severity of the infection 1
- Importance of addressing underlying factors: catheter removal, proper hydration, and good perineal hygiene
- Need for susceptibility testing: to guide targeted therapy and minimize the risk of antibiotic resistance 1
From the Research
Chronic Bacteriuria with ESBL Producer E Coli
- Chronic bacteriuria with ESBL producer E coli is a significant concern, as these organisms are frequently resistant to many antimicrobial agents 2.
- Risk factors for community-acquired infections caused by ESBL-producing E coli include age older than 60 years, female sex, diabetes mellitus, recurrent urinary tract infections (UTIs), previous invasive procedures of the urinary tract, follow-up in outpatient clinic, and previous receipt of aminopenicillins, cephalosporins, and fluoroquinolones 2.
- For patients with bacteremia due to ESBL-producing E coli, carbapenem therapy, such as ertapenem, imipenem, or meropenem, has been shown to be effective 3.
Treatment Options
- Fosfomycin and amoxicillin-clavulanate appear to be effective for cystitis caused by susceptible isolates of ESBL-producing E coli 2.
- Amikacin may improve the outcome of empirical treatment without increasing carbapenem utilization, as 98% of ESBL E coli were susceptible to amikacin in one study 4.
- The choice of antibiotic should be guided by susceptibility testing, as resistance rates vary widely among different antibiotics and bacterial isolates 5, 6.
Prevention and Control
- The use of urinary catheters is a significant risk factor for the development of bacteriuria and asymptomatic infection with ESBL-producing bacteria 6.
- Control programs for catheter infections are necessary to minimize the risk of infections associated with these medical devices 6.
- Identifying risk factors, such as hospital-acquired infection, prior UTI within 1 year, and underlying cerebrovascular disease, can help guide treatment decisions in the emergency department 4.