From the Guidelines
For sepsis from a urinary tract infection (UTI) in an inpatient setting, empiric broad-spectrum antibiotics should be initiated immediately after obtaining blood and urine cultures, with a recommended first-line treatment typically including an intravenous (IV) combination of a beta-lactam antibiotic plus an aminoglycoside or a fluoroquinolone, as suggested by the European Association of Urology guidelines 1. The choice of antibiotics should be based on the local resistance patterns and the patient's risk factors for resistant organisms. Some key options include:
- Piperacillin-tazobactam (4.5g IV every 6-8 hours)
- Cefepime (2g IV every 8-12 hours)
- Meropenem (1g IV every 8 hours) These can be combined with:
- Gentamicin (5-7mg/kg IV once daily)
- Ciprofloxacin (400mg IV every 12 hours), although its use should be limited to cases where the local resistance rate is <10% and the patient does not require hospitalization or has not used fluoroquinolones in the last 6 months, as recommended by the European Association of Urology guidelines 1. It is also crucial to manage any urological abnormality and/or underlying complicating factors, as emphasized by the guidelines 1. Treatment should be narrowed based on culture results, typically within 48-72 hours, and the total duration is generally 7-10 days, though this may be extended for complicated cases, as suggested by the Surviving Sepsis Campaign guidelines 1. Prompt antibiotic administration is crucial, as each hour of delay in sepsis increases mortality, and source control through urinary catheterization or drainage of obstructions is equally important alongside fluid resuscitation and hemodynamic support. The Surviving Sepsis Campaign guidelines also recommend daily assessment for de-escalation of antimicrobial therapy in patients with sepsis and septic shock 1. Overall, the management of sepsis from UTI in an inpatient setting requires a multifaceted approach that includes prompt antibiotic administration, source control, and careful consideration of the patient's risk factors and local resistance patterns.
From the FDA Drug Label
Gentamicin Injection, USP is indicated in the treatment of serious infections caused by susceptible strains of the following microorganisms: Pseudomonas aeruginosa, Proteus species (indole-positive and indole-negative), Escherichia coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species and Staphylococcus species (coagulase-positive and coagulase-negative) Clinical studies have shown gentamicin injection to be effective in bacterial neonatal sepsis; bacterial septicemia and serious bacterial infections of the central nervous system (meningitis), urinary tract, respiratory tract, gastrointestinal tract (including peritonitis), skin, bone and soft tissue (including burns) Gentamicin injection may be considered as initial therapy in suspected or confirmed gram-negative infections, and therapy may be instituted before obtaining results of susceptibility testing
The best antibiotics for sepsis from a urinary tract infection (UTI) in an inpatient may include gentamicin, as it is effective against serious bacterial infections of the urinary tract and has been shown to be effective in bacterial septicemia 2.
- Key considerations:
- Susceptibility of the causative organism to gentamicin
- Severity of the infection
- Potential for toxicity
- Additional therapy may be necessary, such as a penicillin-type or cephalosporin-type drug, depending on the causative organism and its susceptibility.
From the Research
Treatment Options for Sepsis from UTI
The treatment of sepsis from a urinary tract infection (UTI) depends on the causative pathogen and its susceptibility pattern.
- For acute uncomplicated bacterial cystitis, first-line empiric therapies include a 5-day course of nitrofurantoin or a 3-g single dose of fosfomycin tromethamine 3, 4.
- Second-line options include fluoroquinolones and β-lactams, such as amoxicillin-clavulanate 3, 4.
- For UTIs due to AmpC- β-lactamase-producing organisms, treatment options include fosfomycin, nitrofurantoin, fluoroquinolones, cefepime, piperacillin-tazobactam, and carbapenems 3, 4.
- For UTIs due to ESBL-producing Enterobacteriaceae, treatment options include nitrofurantoin, fosfomycin, fluoroquinolones, cefoxitin, piperacillin-tazobactam, carbapenems, ceftazidime-avibactam, ceftolozane-tazobactam, and aminoglycosides 3, 4.
Carbapenem-Resistant Enterobacteriaceae (CRE)
For UTIs caused by CRE, treatment options include ceftazidime-avibactam, meropenem/vaborbactam, imipenem/cilastatin-relebactam, colistin, fosfomycin, aztreonam, and aminoglycosides including plazomicin, cefiderocol, and tigecycline 3, 4.
Multidrug-Resistant (MDR) Pseudomonas spp.
For UTIs caused by MDR-Pseudomonas spp., treatment options include fluoroquinolones, ceftazidime, cefepime, piperacillin-tazobactam, carbapenems, aminoglycosides, colistin, ceftazidime-avibactam, and ceftolozane-tazobactam 3, 4.
Clinical Trials
A randomized clinical trial (TANGO I) compared the efficacy and safety of meropenem-vaborbactam with piperacillin-tazobactam in patients with complicated UTI, including acute pyelonephritis 5.
- The results showed that meropenem-vaborbactam was non-inferior to piperacillin-tazobactam in terms of clinical cure or improvement and microbial eradication.
- Another study compared the efficacy and safety of meropenem with ceftazidime, alone or combined with amikacin, in patients with septicaemia 6.
- The results showed that meropenem was as effective as ceftazidime, alone or combined with amikacin, in the empirical treatment of septicaemia.
Sepsis Treatment
For sepsis from UTI, the treatment should be guided by the results of urine culture and susceptibility testing 3, 4.
- Empiric therapy should be started promptly, and the choice of antibiotic should be based on the suspected causative pathogen and its susceptibility pattern.
- The use of broad-spectrum antibiotics, such as carbapenems, should be reserved for patients with severe infections or those who are at risk of infection with resistant organisms 3, 4.