What is the second choice of antibiotic for a patient with Klebsiella pneumoniae urinary tract infection (UTI) already receiving Piptaz (Piperacillin/Tazobactam)?

From the Guidelines

For a patient with Klebsiella pneumoniae urinary tract infection (UTI) already receiving piperacillin-tazobactam, a second choice of antibiotic could be a carbapenem such as meropenem (1 gram IV every 8 hours) or ertapenem, considering the potential for resistance and the need for broad coverage. Given the patient is already on piperacillin-tazobactam, the selection of a second antibiotic should be guided by the severity of the infection, local resistance patterns, and the patient's clinical condition 1. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines suggest that for patients with infections due to third-generation cephalosporin-resistant Enterobacterales (3GCephRE), which includes Klebsiella pneumoniae, a carbapenem such as imipenem or meropenem is recommended as targeted therapy for severe infections 1. However, for non-severe infections, options like piperacillin-tazobactam, amoxicillin/clavulanic acid, or quinolones may be considered, with the caveat that antibiotic stewardship principles should guide the choice 1. Since the patient is already on piperacillin-tazobactam, moving to a carbapenem like meropenem or considering ertapenem as an alternative, especially if there are concerns about resistance or the infection's severity, would be a logical step, keeping in mind the need to adjust therapy based on culture and susceptibility results to ensure effective treatment and minimize resistance development 1. Key considerations include:

• The severity of the UTI and the patient's clinical condition
• Local antimicrobial resistance patterns
• The potential for the pathogen to be an extended-spectrum beta-lactamase (ESBL) producer
• The need for antibiotics with good urinary penetration
• The importance of narrowing antibiotic therapy once susceptibility results are available to prevent further resistance development. In the context of real-life clinical practice, prioritizing morbidity, mortality, and quality of life, the choice of a second antibiotic should lean towards ensuring broad coverage and effectiveness against potential resistant organisms, while also considering the principles of antibiotic stewardship 1.

From the Research

Second Choice of Antibiotic for Klebsiella pneumoniae UTI

• For a patient with Klebsiella pneumoniae urinary tract infection (UTI) already receiving Piptaz (Piperacillin/Tazobactam), the second choice of antibiotic can be considered based on the following options:
  • Ceftolozane-tazobactam: This antibiotic has shown efficacy against ESBL-producing Klebsiella pneumoniae in clinical trials 2.
  • Meropenem/vaborbactam: This combination has demonstrated excellent in vitro activity against Gram-negative clinical isolates, including KPC- and ESBL-producing Enterobacteriaceae, including Klebsiella pneumoniae 3.
  • Cefepime: This antibiotic is a treatment option for UTIs due to AmpC-β-lactamase-producing Enterobacteriaceae, including Klebsiella pneumoniae 4.
  • Carbapenems: These antibiotics, including meropenem and imipenem/cilastatin-relebactam, are treatment options for UTIs due to ESBL-producing Enterobacteriaceae, including Klebsiella pneumoniae 4.

Considerations for Antibiotic Selection

• The selection of a second-choice antibiotic should be based on local susceptibility patterns and the patient's specific clinical situation.
• It is essential to use new antimicrobials wisely to avoid resistance development 4.
• The efficacy and safety of different antibiotic options should be considered, as well as potential interactions with other medications the patient may be taking.