From the Guidelines
Nitrofurantoin is not recommended for complicated ESBL UTIs due to its inadequate tissue concentrations for complicated infections. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines suggest alternative treatments for complicated urinary tract infections (cUTIs) caused by multidrug-resistant Gram-negative bacilli, including ESBL-producing Enterobacterales 1.
For complicated ESBL UTIs, intravenous fosfomycin, carbapenems like meropenem, or piperacillin-tazobactam are considered effective treatment options 1. Key points to consider include:
- Intravenous fosfomycin has been compared with piperacillin-tazobactam and meropenem in two RCTs, showing no significant differences in clinical or microbiological cure for patients with cUTI or bacteraemic cUTI caused by ESBL-producing Enterobacterales 1.
- Carbapenems, such as meropenem (1g IV every 8 hours) or ertapenem (1g IV daily), are typically first-line treatments for complicated ESBL UTIs.
- Alternative options include piperacillin-tazobactam at high doses (4.5g IV every 6 hours with extended infusion) or ceftazidime-avibactam (2.5g IV every 8 hours), though susceptibility testing is essential.
- Treatment duration should be 7-14 days depending on clinical response.
- Fosfomycin may be considered for lower UTIs if susceptibility is confirmed, but its use in complicated UTIs is limited due to concerns about heart failure, as seen in the FOREST trial 1.
- Patients with complicated UTIs often require initial IV therapy followed by oral step-down therapy based on susceptibility results.
- Addressing any underlying anatomical abnormalities or removing indwelling catheters is crucial for successful treatment.
- Consultation with an infectious disease specialist is advisable for optimal management of these resistant infections.
From the Research
Nitrofurantoin for Complicated ESBL UTI
- Nitrofurantoin has been studied as a potential treatment option for complicated ESBL UTIs 2, 3, 4, 5, 6.
- The studies suggest that nitrofurantoin may be an effective treatment option for ESBL-producing E. coli-related lower urinary tract infections, with clinical and microbiological success rates ranging from 68% to 83.2% 3, 5, 6.
- However, the effectiveness of nitrofurantoin against ESBL-producing Klebsiella pneumoniae is lower, ranging from 2.4% to 40% 2, 3, 4, 6.
- Nitrofurantoin may be an alternative option for uncomplicated UTIs with ESBL-EC in certain regions, such as Taiwan 2.
- The use of nitrofurantoin in the treatment of ESBL-producing E. coli-related LUTI has been shown to have re-infection and relapse rates of 6.5% and 3.2%, respectively 5.
Key Findings
- Nitrofurantoin is effective against ESBL-producing E. coli, with high sensitivity rates 3, 5, 6.
- Nitrofurantoin may not be as effective against ESBL-producing Klebsiella pneumoniae 2, 3, 4, 6.
- Nitrofurantoin can be used as an alternative treatment option for uncomplicated UTIs with ESBL-EC in certain regions 2.
- The use of nitrofurantoin in the treatment of ESBL-producing E. coli-related LUTI has been shown to have relatively low re-infection and relapse rates 5.
Antibiotic Sensitivity
- Nitrofurantoin has been shown to have high sensitivity rates against ESBL-producing E. coli, ranging from 83.2% to 93% 3, 5, 6.
- Nitrofurantoin has lower sensitivity rates against ESBL-producing Klebsiella pneumoniae, ranging from 2.4% to 40% 2, 3, 4, 6.
- Other antibiotics, such as mecillinam and fosfomycin, have also been shown to be effective against ESBL-producing E. coli and Klebsiella pneumoniae 3, 4, 6.