From the Guidelines
For a patient with a urinary tract infection who is allergic to ceftriaxone, the most suitable alternative antibiotic is nitrofurantoin (100 mg four times daily for 5-7 days) or trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), as recommended by the European Association of Urology guidelines 1. When considering alternative antibiotics for a patient with a UTI who is allergic to ceftriaxone, it's essential to take into account the severity of the infection, local resistance patterns, and patient factors.
- For uncomplicated UTIs, nitrofurantoin is a reasonable first-line agent, according to the Wikiguidelines group consensus statement 1.
- For patients with pyelonephritis, trimethoprim-sulfamethoxazole (TMP/SMX) represents a reasonable first-line agent, but the choice should be dependent upon local resistance rates 1.
- Fluoroquinolones, such as ciprofloxacin, can be used as an alternative, but only if the local resistance rate is <10% and the patient does not require hospitalization 1.
- Fosfomycin (3 g single dose) is another effective option for uncomplicated UTIs.
- For complicated UTIs or pyelonephritis, alternatives might include carbapenems like meropenem or aminoglycosides such as gentamicin. It's crucial to note that cross-reactivity between ceftriaxone and other beta-lactams exists, so penicillins should generally be avoided in patients with severe cephalosporin allergies. The selection of antibiotic should be guided by urine culture results when available to ensure the chosen antibiotic is effective against the specific pathogen 1. Patients should complete the full course of antibiotics even if symptoms improve before completion to prevent recurrence and antimicrobial resistance.
From the FDA Drug Label
CLINICAL STUDIES Complicated Urinary Tract Infection and Pyelonephritis – Efficacy in Pediatric Patients Ciprofloxacin, administered I. V. and/or orally, was compared to a cephalosporin for treatment of complicated urinary tract infections (cUTI) and pyelonephritis in pediatric patients The clinical success and bacteriologic eradication rates in the Per Protocol population were similar between ciprofloxacin and the comparator group Clinical Response at 5 to 9 Days Post-Treatment 95.7% (202/211) Bacteriologic Eradication by Patient at 5 to 9 Days Post-Treatment* 84.4% (178/211) Bacteriologic Eradication of the Baseline Pathogen at 5 to 9 Days Post-Treatment Escherichia coli 156/178 (88%)
For a patient with a urinary tract infection (UTI) who is allergic to ceftriaxone, ciprofloxacin can be considered as a suitable alternative antibiotic.
- Key points:
- Ciprofloxacin has been shown to be effective in treating complicated UTIs and pyelonephritis in pediatric patients.
- The clinical success and bacteriologic eradication rates of ciprofloxacin are similar to those of a cephalosporin.
- Ciprofloxacin has a high rate of bacteriologic eradication of Escherichia coli, a common cause of UTIs. 2
From the Research
Alternative Antibiotics for UTI
For a patient with a urinary tract infection (UTI) who is allergic to ceftriaxone, several alternative antibiotics can be considered. The choice of antibiotic depends on the severity of the infection, the patient's medical history, and local resistance patterns.
First-Line Options
- Nitrofurantoin: a 5-day course is recommended for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females 3
- Fosfomycin tromethamine: a 3-g single dose is recommended for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females 3
- Pivmecillinam: a 5-day course is recommended for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females 3
Second-Line Options
- Oral cephalosporins such as cephalexin or cefixime 3
- Fluoroquinolones such as ciprofloxacin 4, 5
- β-lactams such as amoxicillin-clavulanate 3, 6
Treatment of UTIs due to Specific Organisms
- For UTIs due to AmpC-β-lactamase-producing Enterobacteriales: nitrofurantoin, fosfomycin, pivmecillinam, fluoroquinolones, cefepime, piperacillin-tazobactam, and carbapenems 3
- For UTIs due to ESBL-E coli: nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 3
- For UTIs due to ESBL-Klebsiella pneumoniae: pivmecillinam, fosfomycin, finafloxacin, and sitafloxacin 3
Parenteral Treatment Options
- For UTIs due to ESBL-producing Enterobacteriales: piperacillin-tazobactam, carbapenems, ceftazidime-avibactam, ceftolozane-tazobactam, aminoglycosides, and fosfomycin 3
- For UTIs caused by carbapenem-resistant Enterobacteriales: ceftazidime-avibactam, meropenem/vaborbactam, imipenem/cilastatin-relebactam, colistin, fosfomycin, aztreonam, and amoxicillin-clavulanate 3