Management of Severe UTI in a Hospitalized Patient on Empagliflozin (Jardiance)
For a hospitalized patient with severe UTI who is taking Jardiance (empagliflozin) for diabetes, the SGLT2 inhibitor should be temporarily discontinued due to the increased risk of urosepsis and pyelonephritis, and broad-spectrum parenteral antibiotics should be initiated immediately.
Initial Assessment and Management
Discontinue Jardiance
- Immediately discontinue empagliflozin (Jardiance) due to the FDA warning about urosepsis and pyelonephritis risk 1
- SGLT2 inhibitors increase urinary glucose excretion, potentially creating a favorable environment for bacterial growth
- The FDA label specifically warns about urosepsis and pyelonephritis as serious adverse events requiring prompt evaluation and treatment 1
Antibiotic Therapy
- Start with broad-spectrum parenteral antibiotics that cover gram-positive cocci, gram-negative organisms, and anaerobes 2
- Recommended initial empiric regimens:
- Fluoroquinolones (ciprofloxacin 400mg IV q12h or levofloxacin 750mg IV daily)
- Extended-spectrum cephalosporins (ceftriaxone 1-2g IV daily)
- Piperacillin-tazobactam 3.375g IV q6h for broader coverage
- Adjust antibiotic selection based on local resistance patterns and patient factors
- Modify therapy once culture and sensitivity results are available
Stabilize the Patient
- Restore fluid and electrolyte balance 3
- Correct hyperglycemia, hyperosmolality, acidosis, and azotemia 3
- Monitor vital signs, urine output, and markers of infection (WBC, CRP, procalcitonin)
- Ensure adequate hydration with IV fluids
Diagnostic Workup
- Obtain urine culture and sensitivity testing before initiating antibiotics if possible 2
- Blood cultures are essential to rule out bacteremia 2
- Consider imaging (ultrasound or CT) to assess for complications such as:
- Obstruction
- Abscess formation
- Emphysematous pyelonephritis (more common in diabetic patients)
Glycemic Management During Infection
- Switch to alternative diabetes medications during the acute infection:
- Insulin is typically the preferred agent for inpatient glycemic control
- Target blood glucose 140-180 mg/dL during hospitalization
- Monitor blood glucose more frequently during infection as insulin requirements may increase
- Watch for ketoacidosis, which can occur with SGLT2 inhibitors even with normal blood glucose levels 1
Duration of Therapy and Follow-up
- Continue parenteral antibiotics until clinical improvement (typically 48-72 hours)
- Once improved, transition to oral antibiotics based on culture results
- Total antibiotic duration:
- 7-14 days for complicated UTI/pyelonephritis
- Longer duration may be needed if bacteremia is present
Considerations for Restarting Jardiance
- Reassess the risk-benefit ratio of restarting empagliflozin after complete resolution of the UTI
- Consider alternative diabetes medications if:
- Patient has had recurrent UTIs
- Evidence of incomplete bladder emptying or urinary retention
- History of urinary tract abnormalities
Pitfalls and Caveats
- Do not delay antibiotic therapy while waiting for culture results in a severely ill patient
- Avoid fluoroquinolones if there is high local resistance (>20%)
- Be vigilant for signs of ketoacidosis in patients recently on SGLT2 inhibitors, even with normal blood glucose levels 1
- Monitor renal function closely, as acute kidney injury can occur during severe infections and may be exacerbated by recent SGLT2 inhibitor use 1
- Consider urological evaluation if there are recurrent UTIs after recovery to rule out structural abnormalities
By following this approach, you can effectively manage a hospitalized patient with severe UTI who has been taking empagliflozin, minimizing complications and optimizing outcomes.