What oral antibiotic can be used as an alternative to ceftriaxone (Ceftriaxone) for a urinary tract infection (UTI) susceptible to ceftriaxone?

From the Guidelines

For a urinary tract infection susceptible to ceftriaxone, the most appropriate oral antibiotic alternative is trimethoprim-sulfamethoxazole (TMP-SMX) at a dose of 160/800 mg twice daily for 14 days, as recommended by the European Association of Urology guidelines 1. When considering oral antibiotic alternatives to ceftriaxone for a UTI, several factors such as local resistance patterns, patient allergies, and infection severity must be taken into account.

• The choice of antibiotic should be guided by the susceptibility of the uropathogen, with TMP-SMX being a suitable option if the organism is known to be susceptible 1.
• Fluoroquinolones like ciprofloxacin (500–750 mg twice daily) or levofloxacin (750 mg once daily) for 5-7 days can also be effective, but their use should be reserved for cases where other options are not suitable due to resistance concerns, and the prevalence of fluoroquinolone resistance should be less than 10% 1.
• Oral cephalosporins such as cefpodoxime (200 mg twice daily) for 10 days are also effective alternatives 1. The European Association of Urology guidelines provide a summary of suggested regimens for empirical oral antimicrobial therapy for uncomplicated pyelonephritis, including the dosages and durations for various antibiotics 1.
• It is essential to note that if fluoroquinolones are used empirically, an initial intravenous dose of a long-acting parenteral antimicrobial, such as ceftriaxone, should be administered 1. Overall, the selection of an oral antibiotic alternative to ceftriaxone for a UTI should be based on the most recent and highest-quality evidence, taking into account the specific characteristics of the infection and the patient.

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 1 to 17 years of age Clinical Success and Bacteriologic Eradication at Test of Cure (5 to 9 Days Post-Therapy) CiprofloxacinComparator

• Patients with baseline pathogen(s) eradicated and no new infections or superinfections/total number of patients. There were 5.5% (6/211) ciprofloxacin and 9. 5% (22/231) comparator patients with superinfections or new infections.

Ciprofloxacin can be used as an alternative to ceftriaxone for a urinary tract infection (UTI) susceptible to ceftriaxone, as it has shown clinical success and bacteriologic eradication rates similar to those of a cephalosporin comparator in clinical trials 2.

• Key points:
  • Ciprofloxacin has been compared to a cephalosporin in the treatment of complicated urinary tract infections.
  • The clinical success and bacteriologic eradication rates were similar between ciprofloxacin and the comparator group.
  • Ciprofloxacin can be administered orally for the treatment of UTIs.

From the Research

Oral Antibiotic Alternatives to Ceftriaxone for UTI

For a urinary tract infection (UTI) susceptible to ceftriaxone, several oral antibiotics can be considered as alternatives. The choice of antibiotic depends on various factors, including the severity of the infection, patient's medical history, and local susceptibility 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: Cephalexin or cefixime can be used as second-line options 3.
• Fluoroquinolones: Can be used as second-line options, but high rates of resistance may preclude their use in some communities 3.
• β-lactams: Amoxicillin-clavulanate can be used as a second-line option 3.

Specific Oral Antibiotics

• Cefixime: Has been shown to be effective in treating UTIs, including those caused by ESBL-producing Enterobacteriaceae 4, 5.
• Cefazolin: Exhibits high susceptibility for uropathogens commonly implicated in cases of uncomplicated UTI, and may be a suitable alternative to ceftriaxone for inpatient treatment of UTIs 6.

Considerations

• Local susceptibility patterns and patient's medical history should be taken into account when choosing an oral antibiotic alternative to ceftriaxone.
• The risk of hospital-onset Clostridioides difficile infection (HOCDI) should also be considered, as ceftriaxone has been shown to increase this risk more than other antibiotics 6.