What is the best course of action for a patient with a history of neurogenic bladder and chronic kidney disease who presents with recurrent urinary tract infection (UTI) symptoms, including bilateral flank pain, pelvic pain, dysuria, and hematuria, after initial improvement with Augmentin (amoxicillin-clavulanate)?

From the Guidelines

The best course of action for this patient is to immediately obtain a urine culture and sensitivity testing, and initiate empiric therapy with a fluoroquinolone, such as ciprofloxacin 500mg twice daily or levofloxacin 750mg once daily for 7-14 days, adjusting the dose based on kidney function, while also evaluating for possible urologic abnormalities with imaging studies and considering urologic consultation for possible urodynamic studies. This approach is guided by the patient's history of neurogenic bladder and chronic kidney disease, which puts them at higher risk for complicated UTIs and kidney damage, as noted in the AUA/SUFU guideline on adult neurogenic lower urinary tract dysfunction 1. Given the patient's symptoms of bilateral flank pain, pelvic pain, dysuria, and hematuria after initial improvement with Augmentin, it is crucial to address both the acute infection and the underlying factors contributing to recurrence. The patient's presentation with new or worsening symptoms, such as fever, flank pain, and hematuria, warrants additional assessment, as outlined in the guideline's Statement Twelve, which emphasizes the importance of educating patients with NLUTD on the signs and symptoms that would warrant additional assessment 1. Key considerations in management include:

• Obtaining a urine culture and sensitivity testing to guide antibiotic therapy
• Empiric therapy with a fluoroquinolone, adjusting the dose based on kidney function
• Evaluating for possible urologic abnormalities with imaging studies, such as ultrasound or CT scan
• Considering urologic consultation for possible urodynamic studies to assess bladder function
• Long-term management strategies, such as prophylactic antibiotics, intermittent catheterization, or non-antibiotic preventive measures, like methenamine hippurate
• Supportive measures, including increased fluid intake and prompt voiding, unless contraindicated by kidney disease. Given the complexity of this patient's condition and the need for comprehensive management, it is essential to prioritize a thorough evaluation and tailored treatment approach, as suggested by the guideline's recommendations for moderate-risk and high-risk NLUTD patients 1.

From the FDA Drug Label

14.7 Complicated Urinary Tract Infections and Acute Pyelonephritis: 5 Day Treatment Regimen To evaluate the safety and efficacy of the higher dose and shorter course of levofloxacin, 1109 patients with cUTI and AP were enrolled in a randomized, double-blind, multicenter clinical trial conducted in the U.S. from November 2004 to April 2006 comparing levofloxacin 750 mg I. V. or orally once daily for 5 days (546 patients) with ciprofloxacin 400 mg I. V. or 500 mg orally twice daily for 10 days (563 patients).

The patient has a history of neurogenic bladder and chronic kidney disease with recurrent urinary tract infection (UTI) symptoms. Given the patient's symptoms of bilateral flank pain, pelvic pain, dysuria, and hematuria, and the fact that the initial improvement with Augmentin was followed by a recurrence of symptoms, it is likely that the patient has developed a complicated urinary tract infection (cUTI) or acute pyelonephritis (AP).

• The best course of action would be to consider a different antibiotic regimen, such as levofloxacin, which has been shown to be effective in treating cUTI and AP in clinical trials 2.
• However, it is essential to consider the patient's underlying renal disease and potential drug interactions before initiating any new antibiotic therapy.
• Given the patient's complex medical history, it is crucial to consult with a nephrologist and urologist to determine the best course of action and to rule out any underlying conditions that may be contributing to the recurrent UTIs.

From the Research

Patient Presentation and History

The patient presents with recurrent urinary tract infection (UTI) symptoms, including bilateral flank pain, pelvic pain, dysuria, and hematuria, after initial improvement with Augmentin (amoxicillin-clavulanate). The patient has a history of neurogenic bladder and chronic kidney disease, and follows up with urology and nephrology for these conditions.

Treatment Considerations

• The patient's urine culture was positive and susceptible to Augmentin, but symptoms returned after initial improvement, suggesting possible treatment failure or resistance.
• The patient's symptoms, including bilateral flank pain and fever, suggest a complicated UTI or possible pyelonephritis.
• Consideration should be given to using a fluoroquinolone antibiotic, such as levofloxacin or ciprofloxacin, which have been shown to be effective in treating complicated UTIs and pyelonephritis 3, 4, 5, 6.

Fluoroquinolone Treatment Options

• Levofloxacin 750 mg once daily for 5 days has been shown to be noninferior to ciprofloxacin 400/500 mg twice daily for 10 days in treating complicated UTIs and pyelonephritis 6.
• Ciprofloxacin 1000 mg extended release once daily for 7-14 days has been shown to be effective in treating complicated UTIs and pyelonephritis 4.
• Short-course therapy with ciprofloxacin (3-5 days) has been shown to be statistically equivalent to conventional (7-day) therapy with either ciprofloxacin or norfloxacin in treating uncomplicated UTIs 7.

Next Steps

• Consider obtaining a new urine culture to guide further treatment.
• Consult with urology and nephrology to discuss treatment options and ensure coordination of care.
• Consider using a fluoroquinolone antibiotic, such as levofloxacin or ciprofloxacin, as an alternative treatment option.