What alternative antibiotics should be initiated in a patient with a urinary tract infection (UTI) and rising white blood cell (WBC) count, currently being treated with Cipro (ciprofloxacin) and having a Foley catheter in place?

From the Guidelines

For a patient with a urinary tract infection, rising WBC count despite ciprofloxacin treatment, and a Foley catheter in place, I recommend switching to broader-spectrum antibiotics such as piperacillin-tazobactam (Zosyn) 3.375g IV every 6 hours or meropenem 1g IV every 8 hours, as suggested by the most recent guidelines 1. These medications provide coverage against resistant gram-negative organisms, including Pseudomonas, which are common in catheter-associated UTIs. The rising WBC count suggests treatment failure with ciprofloxacin, likely due to antimicrobial resistance or a complicated infection related to the catheter. Additionally, the Foley catheter should be removed or replaced if clinically feasible, as it serves as a nidus for infection and biofilm formation that impairs antibiotic effectiveness, as recommended by the Infectious Diseases Society of America guidelines 1. Obtaining urine and blood cultures before changing antibiotics is crucial to guide targeted therapy once susceptibility results are available, as emphasized by the 2009 international clinical practice guidelines 1. The duration of treatment typically ranges from 7-14 days depending on clinical response, with longer courses needed for complicated infections. Fluoroquinolone resistance is increasingly common in healthcare settings, particularly in patients with indwelling catheters, which explains why ciprofloxacin may be failing in this scenario, and alternative treatments should be considered based on the latest guidelines from the European Association of Urology 1 and the European Society of Clinical Microbiology and Infectious Diseases 1.

Some key points to consider in the management of this patient include:

• The use of combination therapy for complicated UTIs, as recommended by the European Association of Urology guidelines 1
• The importance of managing any urological abnormality and/or underlying complicating factors, as emphasized by the European Association of Urology guidelines 1
• The need to avoid 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, as recommended by the European Association of Urology guidelines 1
• The consideration of antibiotic stewardship in the choice of antibiotic treatment, as emphasized by the European Society of Clinical Microbiology and Infectious Diseases guidelines 1

From the Research

Alternative Antibiotics for UTI Treatment

Given the patient's rising white blood cell (WBC) count despite being treated with Cipro (ciprofloxacin) for a urinary tract infection (UTI) and having a Foley catheter in place, alternative antibiotics should be considered. The following options are based on the provided evidence:

• Cephalosporins: Oral cephalosporins such as cephalexin or cefixime can be considered as second-line options for UTI treatment 2.
• Fluoroquinolones and β-lactams: Fluoroquinolones and β-lactams, such as amoxicillin-clavulanate, can also be used as alternative treatments for UTI 2.
• Meropenem-Vaborbactam: This combination carbapenem/beta-lactamase inhibitor has shown efficacy in treating complicated UTIs, including those caused by ESBL-producing Enterobacteriaceae 3.
• Cefepime-Taniborbactam: This investigational β-lactam and β-lactamase inhibitor combination has demonstrated superiority over meropenem in treating complicated UTIs, including those caused by carbapenem-resistant Enterobacteriaceae 4.
• Ceftolozane-Tazobactam: This combination has shown high clinical cure rates in treating UTIs caused by ESBL-producing Escherichia coli and Klebsiella pneumoniae 5.
• Piperacillin-Tazobactam: This beta-lactam penicillin combination can be an equal or better choice compared to fluoroquinolones, cephalosporins, or gentamicin in patients with risk factors for antibiotic resistance 6.

Key Considerations

When selecting an alternative antibiotic, it is essential to consider the patient's risk factors for antibiotic resistance, such as:

• Residence in nursing homes
• Male gender
• Hospitalization within the last 30 days
• Renal transplantation
• Antibiotic treatment within the last 30 days
• Indwelling urinary catheter
• Recurrent UTI 6

Treatment Options for Specific Pathogens

The following treatment options are recommended for specific pathogens:

• ESBL-producing Enterobacteriaceae: Ceftolozane-tazobactam, meropenem-vaborbactam, or cefepime-taniborbactam can be used 2, 3, 5.
• Carbapenem-resistant Enterobacteriaceae: Cefepime-taniborbactam, meropenem-vaborbactam, or ceftazidime-avibactam can be used 2, 4.
• Multidrug-resistant Pseudomonas spp.: Fluoroquinolones, ceftazidime, cefepime, piperacillin-tazobactam, or carbapenems can be used 2.