What is the treatment for Extended-Spectrum Beta-Lactamase (ESBL) positive Escherichia coli (E. coli) urinary tract infection (UTI)?

From the Guidelines

For ESBL positive E. coli urinary tract infections, the recommended treatment is intravenous fosfomycin, as it has shown no significant differences in clinical or microbiological cure compared to carbapenems, such as meropenem, in patients without septic shock, with or without bacteraemia 1.

Treatment Options

• Intravenous fosfomycin is a suitable option for the treatment of ESBL positive E. coli UTIs, with high-certainty evidence supporting its use in patients without septic shock, with or without bacteraemia 1.
• In less severe cases or for outpatient treatment, oral fosfomycin 3g as a single dose can be considered, although the evidence for this is of very low certainty due to the high risk of bias in the observational study 1.
• Carbapenems, such as ertapenem, can also be used, but their use should be reserved for more severe cases or when other options are not available.

Important Considerations

• The choice of antibiotic should be based on susceptibility testing results, as ESBL-producing E. coli are resistant to many common antibiotics, including cephalosporins and penicillins.
• Adequate hydration and urinary frequency can help flush out bacteria and support the treatment of the infection.
• Contact precautions should be implemented to prevent the spread of ESBL-producing organisms in healthcare settings.
• Follow-up urine cultures after treatment completion are recommended to ensure eradication of the infection.
• Patient education on the importance of completing the full course of antibiotics and the potential for recurrence or spread of resistant organisms is crucial.

Evidence Quality

• The evidence for the use of intravenous fosfomycin in the treatment of ESBL positive E. coli UTIs is of high certainty, based on two randomized controlled trials (ZEUS and FOREST) that showed no significant differences in clinical or microbiological cure compared to carbapenems 1.
• The evidence for the use of oral fosfomycin is of very low certainty due to the high risk of bias in the observational study 1.

From the Research

Treatment Options for ESBL-Positive E. coli UTI

• Carbapenems are often used to treat ESBL-positive E. coli UTI, with 50% of parenchymal infections being treated with a carbapenem 2
• Alternative oral treatment options are being explored, with studies showing that cefixime and amoxicillin/clavulanate combination therapy could be an effective oral outpatient treatment option for ESBL-EC 3
• Other oral antibiotics such as fosfomycin, pivmecillinam, and nitrofurantoin have shown high susceptibility rates and could be considered important oral treatment options 4
• Doxycycline hyclate may also be an effective treatment option for patients with susceptible MDR UTI, due to its oral formulation, wide spectrum of activity, and low toxicity 5

Antibiotic Susceptibility Profile

• ESBL-positive E. coli isolates are often multidrug resistant, with high resistance rates to fluoroquinolones, trimethoprim, and cephalexin 6
• Carbapenems and nitrofurantoin remain effective against ESBL-positive E. coli, and may guide empirical antibiotic therapy 6
• Antibiotic susceptibility testing is crucial in guiding treatment, with synergistic testing showing promise in predicting successful treatment outcomes 3

Risk Factors and Incidence

• The incidence of ESBL-producing E. coli in urine cultures is increasing, with a 44% increase from 2006 to 2014 6
• Male gender, urinary catheterisation, inpatient status, and increasing age are identified as risk factors for ESBL infection or colonisation 6