From the Guidelines
For patients with UTIs who have allergies to both cephalosporins and fluoroquinolones, nitrofurantoin (Macrobid) 100mg twice daily for 5-7 days is the recommended first-line treatment for uncomplicated lower UTIs. This recommendation is based on the most recent and highest quality study available, which suggests that nitrofurantoin is an effective and safe option for treating UTIs in patients with allergies to cephalosporins and fluoroquinolones 1.
Alternative Treatment Options
Alternative options include:
- Trimethoprim-sulfamethoxazole (Bactrim DS) one double-strength tablet twice daily for 3 days
- Fosfomycin (Monurol) 3g single-dose sachet These alternatives are recommended due to their efficacy and minimal propensity for collateral damage, as noted in the guidelines 1.
Considerations for Treatment
The choice of treatment depends on:
- Infection severity
- Local resistance patterns
- Patient factors like renal function Nitrofurantoin should be avoided in patients with creatinine clearance below 30 ml/min or those with upper UTIs, as it does not achieve adequate tissue concentrations 1.
Recurrent UTIs
For recurrent UTIs in patients with allergies to cephalosporins and fluoroquinolones, consider:
- Antibiotic prophylaxis with nitrofurantoin 50-100mg daily
- Non-antibiotic approaches like cranberry products or vaginal estrogen in postmenopausal women These approaches can help reduce the risk of recurrent UTIs and minimize the use of antibiotics 1.
From the FDA Drug Label
To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. Urinary Tract Infections 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 in patients with an allergy to cephalosporin and fluoroquinolone may include:
- Trimethoprim-sulfamethoxazole (2) for the treatment of urinary tract infections due to susceptible strains of Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris
- Doxycycline (3) may be considered for the treatment of urinary tract infections, although the label does not explicitly state its use for this indication, it can be used for various bacterial infections.
From the Research
Treatment Options for UTI in Patients with Allergy to Cephalosporin and Fluoroquinolone
- For patients with an allergy to cephalosporin and fluoroquinolone, alternative treatment options for UTI include:
- Nitrofurantoin: a 5-day course is recommended for acute uncomplicated bacterial cystitis 4, 5
- Fosfomycin tromethamine: a 3-g single dose is recommended for acute uncomplicated bacterial cystitis 4, 5
- Pivmecillinam: a 5-day course is recommended for acute uncomplicated bacterial cystitis 4, 5
- Amoxicillin-clavulanate: can be used as an alternative for UTIs due to ESBL-producing Enterobacteriaceae 4, 5
- Finafloxacin and sitafloxacin: can be used as oral treatment options for UTIs due to ESBL-producing E. coli and Klebsiella pneumoniae 4
Parenteral Treatment Options
- For patients who require parenteral treatment, options include:
- Piperacillin-tazobactam: for ESBL-E coli only 4
- Carbapenems: including meropenem/vaborbactam, imipenem/cilastatin-relebactam, and sulopenem 4
- Ceftazidime-avibactam and ceftolozane-tazobactam: for UTIs due to ESBL-producing Enterobacteriaceae 4, 5
- Aminoglycosides: including plazomicin, for UTIs caused by carbapenem-resistant Enterobacteriaceae (CRE) and MDR-Pseudomonas spp. 4, 5
Treatment of UTIs Caused by MDR-Organisms
- For UTIs caused by MDR-organisms, treatment options include:
- Ceftazidime-avibactam, meropenem/vaborbactam, imipenem/cilastatin-relebactam, colistin, fosfomycin, aztreonam, and ceftazidime-avibactam, aztreonam, and amoxicillin-clavulanate: for UTIs caused by CRE 4, 5
- Fluoroquinolones, ceftazidime, cefepime, piperacillin-tazobactam, carbapenems, aminoglycosides, colistin, ceftazidime-avibactam, and ceftolozane-tazobactam: for UTIs caused by MDR-Pseudomonas spp. 4, 5