What antibiotic treatment is recommended for a urinary tract infection with high minimum inhibitory concentration (MIC) and resistance to common antibiotics?

From the Guidelines

For urinary tract infections with high MIC values and resistance to common antibiotics, high-dose daptomycin (8-12 mg/kg daily) is recommended as a treatment option, as it has shown efficacy against vancomycin-resistant enterococci (VRE) and has a low risk of adverse effects, such as CK elevation 1. When considering treatment options, it's essential to differentiate between colonization and true infection to avoid unnecessary antibiotic use.

• The choice of antibiotic should be guided by urine culture and susceptibility testing whenever possible.
• High-dose daptomycin has been shown to be effective against VRE, with a low risk of adverse effects, such as CK elevation 1.
• Alternative treatment options may include fosfomycin, nitrofurantoin, or combination therapy with an aminoglycoside and a beta-lactam.
• Treatment duration should be based on individual clinical conditions, with a minimum of 14 days recommended for VRE infections 1.
• It's crucial to monitor CK levels when using high-dose daptomycin, despite the low risk of elevation 1.
• Infection disease specialist consultation is suggested in patients with poor treatment response or when longer duration of treatment is considered 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Urine Analysis and C&S

• In a urine analysis, C&S (culture and sensitivity) is a test used to identify the bacteria causing a urinary tract infection (UTI) and determine the most effective antibiotic treatment 2.
• The minimum inhibitory concentration (MIC) is a measure of the susceptibility of a bacterial strain to a particular antibiotic, with lower MIC values indicating greater susceptibility 2.

Antibiotic Treatment for UTIs with High MIC

• For UTIs with high MIC and resistance to common antibiotics, alternative treatment options may be necessary, such as:
  • Nitrofurantoin
  • Fosfomycin
  • Pivmecillinam
  • Fluoroquinolones (although resistance rates are increasing) 3, 4
• In cases of extended-spectrum β-lactamases (ESBLs)-producing Enterobacteriales, treatment options may include:
  • Carbapenems
  • Ceftazidime-avibactam
  • Cefiderocol
  • Fosfomycin 3

Resistance Patterns and Treatment Guidelines

• Resistance patterns to common antibiotics, such as trimethoprim-sulfamethoxazole and fluoroquinolones, are increasing, making treatment more challenging 3, 5.
• Treatment guidelines recommend using local susceptibility patterns and individualized assessment of risk factors for resistance to choose the optimal empirical regimen 3, 4.
• The use of new antimicrobials should be done wisely to avoid resistance development 3.