What antibiotics should be used to treat a patient with a complicated Urinary Tract Infection (UTI) that has not responded to Augmentin (amoxicillin-clavulanate) and Cefdinir (cefdinir)?

From the Guidelines

For a complicated urinary tract infection that hasn't responded to Augmentin and Cefdinir, an intravenous third-generation cephalosporin as empirical treatment is recommended. This approach is based on the strongest and most recent evidence from the European Association of Urology guidelines on urological infections, which suggests using an intravenous third-generation cephalosporin for empirical treatment of complicated UTI with systemic symptoms 1.

When considering alternative options, the guidelines recommend using a combination of amoxicillin plus an aminoglycoside or a second-generation cephalosporin plus an aminoglycoside 1. However, given the patient's lack of response to Augmentin (amoxicillin-clavulanate) and Cefdinir (a second-generation cephalosporin), an intravenous third-generation cephalosporin is a more appropriate choice.

It's also important to note that ciprofloxacin and other fluoroquinolones should not be used for empirical treatment of complicated UTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months, unless the local resistance rate is <10% and the patient does not require hospitalization 1.

Key considerations in managing the patient include:

• Obtaining urine culture with susceptibility testing to guide targeted therapy
• Considering local antibiogram data, patient allergies, and comorbidities like renal function
• Ensuring adequate hydration and follow-up urine cultures after treatment completion
• Ruling out structural abnormalities or complicated infections that may require imaging studies to identify abscess formation or obstruction.

Overall, the choice of antibiotic should prioritize the patient's specific needs and circumstances, while also adhering to the most recent and highest-quality guidelines available 1.

From the FDA Drug Label

1.9 Complicated Urinary Tract Infections: 5 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis 1.10 Complicated Urinary Tract Infections: 10 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections (mild to moderate) due to Enterococcus faecalis, Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, or Pseudomonas aeruginosa 1.2 Urinary Tract Infections (complicated and uncomplicated) Imipenem and Cilastatin for Injection, USP (I.V.) is indicated for the treatment of urinary tract infections (complicated and uncomplicated) caused by susceptible strains of Enterococcus faecalis, Staphylococcus aureus (penicillinase-producing isolates), Enterobacter species, Escherichia coli, Klebsiella species, Morganella morganii, Proteus vulgaris, Providencia rettgeri, Pseudomonas aeruginosa.

Treatment Options for Complicated UTI:

• Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis.
• Imipenem and Cilastatin for Injection, USP (I.V.) is indicated for the treatment of urinary tract infections (complicated and uncomplicated) caused by susceptible strains of Enterococcus faecalis, Staphylococcus aureus (penicillinase-producing isolates), Enterobacter species, Escherichia coli, Klebsiella species, Morganella morganii, Proteus vulgaris, Providencia rettgeri, Pseudomonas aeruginosa. Considering the patient has not responded to Augmentin and Cefdinir, Levofloxacin or Imipenem and Cilastatin for Injection may be considered as alternative treatment options for complicated UTI, as per the drug labels 2 and 3.

From the Research

Treatment Options for Complicated UTI

The patient has not responded to Augmentin (amoxicillin-clavulanate) and Cefdinir (cefdinir), so alternative treatment options need to be considered.

• Fluoroquinolones, such as ciprofloxacin, levofloxacin, and gatifloxacin, are suitable for the treatment of complicated UTIs 4, 5.
• The dosage regimen for fluoroquinolones should be chosen based on the severity of the infection and the susceptibility of the uropathogens 4.
• Ciprofloxacin, levofloxacin, and gatifloxacin have been shown to be effective in treating UTIs caused by Gram-negative and Gram-positive uropathogens 4, 5.

Specific Treatment Options

• For UTIs caused by Pseudomonas aeruginosa, ciprofloxacin has been shown to be effective 6.
• For UTIs caused by ESBL-producing Enterobacteriaceae, treatment options include fluoroquinolones, such as levofloxacin and ciprofloxacin, as well as other antibiotics like ceftazidime-avibactam and meropenem/vaborbactam 7.
• For UTIs caused by carbapenem-resistant Enterobacteriaceae (CRE), treatment options include ceftazidime-avibactam, meropenem/vaborbactam, and other antibiotics like colistin and fosfomycin 7.

Considerations for Treatment

• The choice of antibiotic should be based on the susceptibility of the uropathogen and the severity of the infection 4, 5.
• The dosage regimen should be chosen to ensure that the antibiotic reaches sufficient concentrations in the urine to eradicate the infection 4, 8.
• The use of fluoroquinolones should be guided by susceptibility testing and local resistance patterns to minimize the development of resistance 5, 7.