From the Guidelines
For urinary tract infections (UTI) with resistance to nitrofurantoin (Macrobid), the most appropriate alternative antibiotic option is trimethoprim-sulfamethoxazole (Bactrim DS) 160/800 mg twice daily for 3 days, as it has been shown to be effective in treating UTIs with minimal resistance and propensity for collateral damage 1. When considering treatment options for UTIs with resistance to Macrobid, it is essential to take into account the local resistance rates of uropathogens and the patient's medical history.
- The choice of antibiotic should ideally be guided by urine culture and sensitivity results.
- In cases of complicated UTIs or pyelonephritis, treatment duration should be extended to 7-14 days.
- Other alternative options include fosfomycin (Monurol) 3 grams as a single dose, or ciprofloxacin 250-500 mg twice daily for 3 days, but these should be reserved for cases where trimethoprim-sulfamethoxazole is not suitable 1.
- For patients with recurrent UTIs and Macrobid resistance, options include cephalexin 500 mg four times daily for 5-7 days or amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days.
- It is crucial to note that resistance to nitrofurantoin occurs when bacteria develop mechanisms to neutralize the drug or prevent it from reaching its target, and patients should complete the full course of antibiotics even if symptoms improve, drink plenty of water, and follow up if symptoms persist 1.
- For pregnant patients or those with renal impairment, medication choices may need adjustment under medical supervision.
From the FDA Drug Label
Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis Levofloxacin tablets are indicated for the treatment of uncomplicated urinary tract infections (mild to moderate) due to Escherichia coli, Klebsiella pneumoniae, or Staphylococcus saprophyticus. For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris
Treatment Options for UTI with Resistance to Macrobid:
- Levofloxacin: can be used to treat uncomplicated and complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis 2
- Trimethoprim-sulfamethoxazole: can be used to treat urinary tract infections due to susceptible strains of Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris 3 Key Considerations:
- The choice of antibiotic should be based on the susceptibility of the causative organism and local epidemiology
- It is essential to consider the potential for resistance when selecting an antibiotic for UTI treatment 2 3
From the Research
UTI Treatment with Resistance to Macrobid
- Macrobid, also known as nitrofurantoin, is a commonly used antibiotic for treating urinary tract infections (UTIs) 4.
- However, in cases where the bacteria are resistant to Macrobid, alternative treatment options are available.
- For acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females, second-line options include:
- Oral cephalosporins such as cephalexin or cefixime
- Fluoroquinolones
- β-lactams, such as amoxicillin-clavulanate 4.
- For UTIs due to AmpC-β-lactamase-producing Enterobacteriales, treatment options include:
- Nitrofurantoin
- Fosfomycin
- Pivmecillinam
- Fluoroquinolones
- Cefepime
- Piperacillin-tazobactam
- Carbapenems 4.
- For UTIs due to ESBLs-E coli, treatment oral options include:
- Nitrofurantoin
- Fosfomycin
- Pivmecillinam
- Amoxicillin-clavulanate
- Finafloxacin
- Sitafloxacin 4.
- Parenteral treatment options for UTIs due to ESBLs-producing Enterobacteriales include:
- Piperacillin-tazobactam (for ESBL-E coli only)
- Carbapenems
- Ceftazidime-avibactam
- Ceftolozane-tazobactam
- Aminoglycosides including plazomicin
- Cefiderocol
- Fosfomycin
- Sitafloxacin
- Finafloxacin 4.