What are the recommended antibiotics for urosepsis in a patient allergic to penicillin (PCN)?

From the Guidelines

For urosepsis in a patient allergic to penicillin, fluoroquinolones and aminoglycosides are recommended as initial empiric treatment options, with carbapenems considered in cases of suspected multidrug-resistant organisms, as per the 2024 European Association of Urology guidelines 1. When considering treatment for urosepsis in patients with a penicillin allergy, it's crucial to choose antibiotics that are effective and have a low risk of cross-reactivity.

• Fluoroquinolones, such as ciprofloxacin or levofloxacin, are suitable options for initial empiric treatment, given their broad-spectrum activity and efficacy in urinary tract infections 1.
• Aminoglycosides, like gentamicin, can also be used, especially in combination with other agents, for their synergistic effects against certain pathogens 1.
• Carbapenems, including meropenem or ertapenem, are reserved for cases where multidrug-resistant organisms are suspected or confirmed, due to their broad-spectrum activity and potential for cross-reactivity with penicillins in some patients 1. Key factors guiding the choice of antibiotic include local resistance patterns, the severity of the penicillin allergy, and the patient's clinical status, including kidney function and potential pregnancy 1.
• Treatment duration typically ranges from 7 to 14 days, depending on the patient's clinical response, with the possibility of de-escalating to oral therapy after initial improvement 1.
• Supportive care, including intravenous fluids and close monitoring of vital signs and urine output, is essential for managing urosepsis effectively 1.

From the FDA Drug Label

Ciprofloxacin Tablets may be administered to adult patients when clinically indicted at the discretions of the physician very 12 hours 7 to 14 days Urinary Tract Infections 250-500 mg every 12 hours 7 to 14 days The dosage of levofloxacin tablets for inhalational anthrax (post-exposure) and plague in pediatric patients who weigh 30 kg or greater is described below in Table 2. Type of Infection*Dosed Every 24 hoursDuration (days)† ... Complicated Urinary Tract Infection (cUTI) or Acute Pyelonephritis (AP)¶ 750 mg5

For a patient allergic to penicillin (PCN) with urosepsis, alternative antibiotics such as ciprofloxacin or levofloxacin can be considered.

• Ciprofloxacin can be administered at a dose of 250-500 mg every 12 hours for 7 to 14 days for urinary tract infections 2.
• Levofloxacin can be administered at a dose of 750 mg every 24 hours for 5 days for complicated urinary tract infection (cUTI) or acute pyelonephritis (AP) 3. It is essential to note that the choice of antibiotic should be based on the severity of the infection, the susceptibility of the causative microorganism, and the patient's renal function. Key considerations:
• The patient's allergy to penicillin should be taken into account when selecting an antibiotic.
• The dosage and duration of treatment may vary depending on the severity of the infection and the patient's response to treatment.
• It is crucial to monitor the patient's renal function and adjust the dosage accordingly.

From the Research

Antibiotic Options for Urosepsis in Patients Allergic to Penicillin

• For patients allergic to penicillin (PCN), alternative antibiotics for urosepsis include:
  • Fluoroquinolones, such as levofloxacin 4, 5
  • Aminoglycosides, such as amikacin 4
  • Carbapenems, such as meropenem/vaborbactam or imipenem/cilastatin-relebactam 6
  • Cephalosporins, such as cefepime or ceftazidime-avibactam, although these may not be suitable for patients with a severe PCN allergy 6
• It is essential to note that the choice of antibiotic should be guided by local susceptibility patterns and the severity of the infection 7, 6
• In cases where ESBL-producing Enterobacteriaceae are suspected, treatment options may include:
  • Nitrofurantoin
  • Fosfomycin
  • Pivmecillinam
  • Fluoroquinolones, such as finafloxacin or sitafloxacin 6
• For patients with urosepsis caused by carbapenem-resistant Enterobacteriaceae (CRE), treatment options may include:
  • Ceftazidime-avibactam
  • Meropenem/vaborbactam
  • Imipenem/cilastatin-relebactam
  • Colistin
  • Fosfomycin
  • Aztreonam
  • Aminoglycosides, such as plazomicin 6

Considerations for Antibiotic Therapy

• Empirical antibiotic therapy should be initiated within the first hour after diagnosis of urosepsis 7
• Urine cultures and blood cultures should be performed before antibiotic treatment to guide therapy 7
• Combination therapy may be necessary in some cases, but should be de-escalated to monotherapy after 48-72 hours 7
• The use of new antimicrobials should be considered carefully to minimize the risk of resistance development 6