What antibiotic regimen is recommended for a patient with a penicillin allergy and concurrent urinary tract infection (UTI) and bacterial sinusitis?

From the Guidelines

For patients with a penicillin allergy and concurrent urinary tract infection (UTI) and bacterial sinusitis, fluoroquinolones, specifically levofloxacin 750 mg once daily for 5-7 days, are recommended as they provide broad-spectrum coverage against common pathogens in both conditions. This recommendation is based on the most recent and highest quality study available, which suggests that fluoroquinolones are effective in treating both UTIs and sinusitis 1. The study published in the Annals of Internal Medicine in 2021 provides best practice advice for the treatment of UTIs, including the use of fluoroquinolones for 5-7 days in patients with uncomplicated pyelonephritis 1. Additionally, a study published in the Journal of Allergy and Clinical Immunology in 2005 supports the use of fluoroquinolones, such as levofloxacin, for the treatment of sinusitis 1.

Some key points to consider when prescribing antibiotics for patients with penicillin allergy and concurrent UTI and sinusitis include:

• Local resistance patterns and patient-specific factors, such as age and renal function, should guide the choice of antibiotic
• Alternative options, such as trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 7-10 days, may be considered, but resistance patterns should be taken into account
• Separate targeted therapies may be needed for patients with severe penicillin allergies who cannot take fluoroquinolones, such as doxycycline 100 mg twice daily for sinusitis and nitrofurantoin 100 mg twice daily for 5-7 days for uncomplicated UTIs
• Adequate hydration and completion of the full course of antibiotics are crucial, even if symptoms improve quickly 1.

It is essential to note that the choice of antibiotic should be guided by the most recent and highest quality evidence available, and patient-specific factors should be taken into consideration to ensure the best possible outcome in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

Adults: The usual dose of oral doxycycline is 200 mg on the first day of treatment (administered 100 mg every 12 hours) followed by a maintenance dose of 100 mg/day In the management of more severe infections (particularly chronic infections of the urinary tract), 100 mg every 12 hours is recommended For the treatment of acute bacterial sinusitis, the recommended dose is not specified in the doxycycline label, but levofloxacin labels provide information on its use for this condition. Levofloxacin is approved for the treatment of acute bacterial sinusitis (ABS) using either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days To evaluate the safety and efficacy of the higher dose and shorter course of levofloxacin, 780 outpatient adults with clinically and radiologically determined acute bacterial sinusitis were evaluated in a double-blind, randomized, prospective, multicenter study comparing levofloxacin 750 mg by mouth once daily for five days to levofloxacin 500 mg by mouth once daily for 10 days

The best antibiotic that covers broad spectrum UTI and bacterial sinusitis for a patient with a penicillin allergy is levofloxacin.

• The recommended dose for levofloxacin in the treatment of acute bacterial sinusitis is 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days.
• For the treatment of complicated urinary tract infections, the recommended dose is 750 mg I.V. or orally once daily for 5 days or 250 mg orally once daily for 10 days.
• Doxycycline may also be considered for the treatment of urinary tract infections, with a recommended dose of 100 mg every 12 hours for more severe infections. 2, 3, 3

From the Research

Antibiotic Regimens for UTI and Bacterial Sinusitis in Patients with Penicillin Allergy

• For patients with a penicillin allergy, the choice of antibiotic regimen for concurrent urinary tract infection (UTI) and bacterial sinusitis should be guided by the severity of the allergy and the suspected pathogens involved 4, 5.
• Fluoroquinolones are broad-spectrum antibiotics that can be used to treat UTI and bacterial sinusitis, but their use is restricted due to the risk of rare adverse effects such as tendinopathy and tendon rupture, peripheral neuropathy, and aortic aneurysm 6.
• In patients with a low-risk penicillin allergy history, a direct amoxicillin challenge may be appropriate, allowing for the use of β-lactam antibiotics 4.
• For patients with a moderate-risk penicillin allergy history, penicillin skin testing can be used to evaluate the risk of an allergic reaction, with a negative predictive value that exceeds 95% 4, 7.
• Cephalosporins can be used in patients with a penicillin allergy, but the risk of cross-reactivity should be considered, particularly with first-generation and second-generation cephalosporins 5, 8.
• Macrolides and fluoroquinolones can also be used as alternative antibiotics, but their use should be guided by antimicrobial stewardship principles to minimize the risk of resistance and adverse events 5, 6.

Considerations for Antibiotic Selection

• The selection of an antibiotic regimen should be based on the severity of the penicillin allergy, the suspected pathogens involved, and the patient's medical history 4, 5.
• A penicillin allergy screening algorithm and penicillin skin testing can be used to identify patients who can safely receive β-lactam antibiotics 7.
• The use of broad-spectrum antibiotics should be minimized to reduce the risk of antimicrobial resistance and adverse events 4, 6.
• Antimicrobial stewardship principles should guide the selection of antibiotic regimens to ensure the optimal use of antibiotics and minimize the risk of resistance and adverse events 4, 5, 6.