What is the recommended antibiotic treatment for a patient with a urinary tract infection (UTI) who is allergic to ceftriaxone (Ceftriaxone) in a hospital setting?

From the Guidelines

For a patient with a urinary tract infection who is allergic to ceftriaxone in a hospital setting, the recommended antibiotic treatment is a fluoroquinolone such as ciprofloxacin (400mg IV every 12 hours) or levofloxacin (750mg IV once daily), as suggested by the European Association of Urology guidelines 1. This recommendation is based on the strength of evidence from recent guidelines, which emphasize the importance of considering local resistance patterns and patient factors, including renal function, when selecting an antibiotic regimen. Some key points to consider when choosing an antibiotic regimen for a patient with a UTI who is allergic to ceftriaxone include:

• The use of fluoroquinolones, such as ciprofloxacin or levofloxacin, as first-line alternatives, as they effectively target common UTI pathogens, including E. coli and other gram-negative bacteria 1.
• The consideration of alternatives, such as aminoglycosides (gentamicin 5-7mg/kg IV once daily) with close monitoring of renal function, or carbapenems like meropenem (1g IV every 8 hours) for more resistant infections 1.
• The importance of guiding the choice of antibiotic by local resistance patterns, patient factors, including renal function, and culture results when available, to prevent antimicrobial resistance development 1.
• The need for adequate hydration and monitoring of clinical response as essential components of management alongside antibiotic therapy. It is also important to note that the European Association of Urology guidelines recommend against using ciprofloxacin and other fluoroquinolones for empirical treatment of complicated UTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months 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. In the absence of such data, local epidemiology and susceptibility patterns may contribute to empiric selection of 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 Complicated Urinary Tract Infection and Pyelonephritis Ciprofloxacin is indicated for the treatment of complicated urinary tract infections and pyelonephritis due to Escherichia coli

For a patient with a urinary tract infection (UTI) who is allergic to ceftriaxone in a hospital setting, the recommended antibiotic treatment could be trimethoprim-sulfamethoxazole or ciprofloxacin, as both are indicated for the treatment of UTIs due to susceptible strains of certain organisms, including Escherichia coli.

• Key considerations:
  • Susceptibility patterns: Should be considered when selecting therapy.
  • Local epidemiology: May contribute to empiric selection of therapy in the absence of susceptibility data.
  • Ciprofloxacin: Not a drug of first choice in the pediatric population due to an increased incidence of adverse events.
  • Trimethoprim-sulfamethoxazole: Should be used only to treat or prevent infections proven or strongly suspected to be caused by susceptible bacteria. 2 3

From the Research

Recommended Antibiotic Treatment for UTI in a Hospital Setting

For a patient with a urinary tract infection (UTI) who is allergic to ceftriaxone in a hospital setting, the recommended antibiotic treatment options are as follows:

• Nitrofurantoin, a 5-day course, is a first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females 4
• Fosfomycin tromethamine, a 3-g single dose, is also a first-line option 4
• Pivmecillinam, a 5-day course, is another first-line option 4
• Second-line options include oral cephalosporins such as cephalexin or cefixime, fluoroquinolones, and β-lactams, such as amoxicillin-clavulanate 4
• For UTIs due to ESBL-producing Enterobacteriales, treatment options include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 4
• Parenteral treatment options for UTIs due to ESBL-producing Enterobacteriales include piperacillin-tazobactam, carbapenems, ceftazidime-avibactam, ceftolozane-tazobactam, and aminoglycosides including plazomicin 4

Considerations for Antibiotic Resistance

It is essential to consider the growing concern of antibiotic-resistant Gram-negative bacteria and the importance of knowing local susceptibility patterns to determine appropriate empiric antibiotic therapy 4

• High rates of resistance to trimethoprim-sulfamethoxazole and ciprofloxacin preclude their use as empiric treatment of UTIs in several communities 4
• The use of new antimicrobials should be done wisely to avoid resistance development 4

Alternative Treatment Options

Other treatment options have been studied, including:

• Nitrofurantoin as an add-on to conventional prophylaxis for the treatment of UTIs in kidney recipients, which did not prove to be effective in preventing UTI development 5
• Single-dose ceftriaxone versus multiple-dose trimethoprim-sulfamethoxazole in the treatment of acute urinary tract infections, which showed similar cure rates 6
• Long-term treatment of urinary tract infection with a single dose of cephalexin or nitrofurantoin in the evening, which was effective in maintaining a bacteriuria-free interval 7