What antibiotic is effective for treating Extended-Spectrum Beta-Lactamase (ESBL) urinary tract infection (UTI)?

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Last updated: March 7, 2025 • View editorial policy

From the Guidelines

For ESBL (Extended-Spectrum Beta-Lactamase) UTIs, intravenous fosfomycin is an effective treatment option, as shown in two RCTs, ZEUS and FOREST, which demonstrated no significant differences in clinical or microbiological cure between intravenous fosfomycin and comparators, including piperacillin-tazobactam and meropenem 1.

Key Considerations

  • Fosfomycin has been compared to other antibiotics, such as meropenem, in the treatment of complicated urinary tract infections (cUTI) caused by ESBL-producing Enterobacterales, and has shown high-certainty evidence for its effectiveness 1.
  • The ZEUS and FOREST trials provide evidence for the use of intravenous fosfomycin in patients with cUTI, including those with bacteraemia, and without septic shock 1.
  • However, the safety of fosfomycin should be considered, particularly in patients at risk for heart failure, as the FOREST trial reported a higher incidence of heart failure in the fosfomycin arm 1.

Treatment Options

  • Intravenous fosfomycin can be used as a carbapenem-sparing treatment option for cUTI caused by ESBL-producing Enterobacterales 1.
  • Other treatment options, such as plazomicin, have also been evaluated, but the evidence is limited to a subgroup analysis of an RCT, and the results are not conclusive 1.
  • Aminoglycosides, such as amikacin or gentamicin, may also be used based on susceptibility testing, but the risk of nephrotoxicity increases after 7 days of therapy 1.

Duration of Treatment

  • The duration of treatment for ESBL UTIs is not well established, but guidelines suggest that treatment should be guided by culture and sensitivity results, and patients should complete the full course of antibiotics even if symptoms improve 2.
  • The optimal duration of treatment for cUTI caused by ESBL-producing Enterobacterales is not clearly defined, but treatment for 7-10 days is commonly recommended 2.

From the FDA Drug Label

Ertapenem is stable against hydrolysis by a variety of beta-lactamases, including penicillinases, and cephalosporinases and extended spectrum beta-lactamases. Gram-negative bacteria: Escherichia coli, Klebsiella pneumoniae The following in vitro data are available, but their clinical significance is unknown At least 90% of the following bacteria exhibit an in vitro minimum inhibitory concentration (MIC) less than or equal to the susceptible breakpoint for ertapenem However, the efficacy of ertapenem in treating clinical infections due to these bacteria has not been established in adequate and well-controlled clinical trials: Gram-negative bacteria: Citrobacter freundii, Citrobacter koseri, Enterobacter aerogenes, Enterobacter cloacae, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella oxytoca (excluding ESBL producing isolates)

The antibiotic ertapenem is effective for treating Extended-Spectrum Beta-Lactamase (ESBL) urinary tract infection (UTI) caused by Escherichia coli and Klebsiella pneumoniae 3.

From the Research

Effective Antibiotics for ESBL UTIs

The following antibiotics have been found to be effective in treating Extended-Spectrum Beta-Lactamase (ESBL) urinary tract infections (UTIs):

  • Nitrofurantoin 4, 5, 6
  • Fosfomycin 4, 5, 6, 7
  • Pivmecillinam 4, 5, 6
  • Amoxicillin-clavulanate 4, 5
  • Finafloxacin 4
  • Sitafloxacin 4
  • Piperacillin-tazobactam 4, 5
  • Carbapenems (e.g. meropenem, imipenem) 4, 5, 8
  • Ceftazidime-avibactam 4, 5
  • Ceftolozane-tazobactam 4, 5
  • Aminoglycosides (e.g. plazomicin) 4, 5

Oral Treatment Options

Oral treatment options for ESBL UTIs include:

  • Pivmecillinam 6
  • Fosfomycin 6, 7
  • Nitrofurantoin 6
  • Amoxicillin-clavulanate 4
  • Finafloxacin 4
  • Sitafloxacin 4

Parenteral Treatment Options

Parenteral treatment options for ESBL UTIs include:

  • Piperacillin-tazobactam 4
  • Carbapenems (e.g. meropenem, imipenem) 4, 8
  • Ceftazidime-avibactam 4
  • Ceftolozane-tazobactam 4
  • Aminoglycosides (e.g. plazomicin) 4

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.