What is the recommended treatment for an Enterobacter cloacae (E. cloacae) urinary tract infection (UTI)?

Treatment of Enterobacter cloacae Urinary Tract Infection

For Enterobacter cloacae UTI, meropenem-vaborbactam (4g IV q8h) is recommended as the most effective treatment option due to its superior efficacy against carbapenem-resistant Enterobacteriaceae and demonstrated clinical success in complicated UTIs. 1, 2

Treatment Algorithm Based on Resistance Pattern

For Non-Resistant E. cloacae UTI:

1. First-line options:

   • Cefepime 1-2g IV every 12 hours for 7-10 days 3
   • Carbapenems (meropenem, imipenem-cilastatin) 4

2. Alternative options:

   • Fluoroquinolones (if susceptible)
   • Trimethoprim-sulfamethoxazole (if susceptible) 5

For Carbapenem-Resistant E. cloacae UTI:

1. First-line options:

   • Meropenem-vaborbactam 4g IV q8h 1, 2
   • Imipenem-cilastatin-relebactam 1.25g IV q6h 1

2. Alternative options:

   • Ceftazidime-avibactam 2.5g IV q8h 1
   • Plazomicin 15 mg/kg IV q12h 1
   • Single-dose aminoglycoside (for simple cystitis only) 1

Evidence Supporting Meropenem-Vaborbactam

Meropenem-vaborbactam has demonstrated superior efficacy in the treatment of complicated UTIs, including those caused by carbapenem-resistant Enterobacteriaceae. In the TANGO I trial, meropenem-vaborbactam showed a 98.4% overall success rate compared to 94.0% with piperacillin-tazobactam, with statistical superiority for microbial eradication 6.

The TANGO II trial specifically evaluated efficacy against carbapenem-resistant Enterobacteriaceae infections and found meropenem-vaborbactam was associated with:

• Decreased 28-day mortality (17.9% vs 33.3%)
• Increased clinical cure rates (64.3% vs 33.3%) compared to best available therapy 7, 8

Treatment Considerations

• Duration of therapy:

  • Uncomplicated UTI: 5-7 days
  • Complicated UTI: 10-14 days 5

• Dosage adjustments:

  • Adjust dosing for renal impairment
  • For cefepime, adjust dose when creatinine clearance is ≤60 mL/min 3

• Monitoring:

  • Clinical response should be assessed within 48-72 hours
  • Repeat cultures only if symptoms persist beyond 48-72 hours of appropriate therapy 5

Important Caveats

• Infectious disease consultation is highly recommended for managing infections caused by multidrug-resistant organisms 1
• Prolonged infusion of β-lactams is recommended for pathogens with high minimum inhibitory concentration (MIC) 1
• Antimicrobial susceptibility testing should guide selection of antimicrobial agents 1
• Regular monitoring of local resistance patterns is essential to guide empiric therapy 5
• For E. cloacae specifically, be aware that it can develop resistance to third-generation cephalosporins during therapy due to inducible AmpC β-lactamases

Emerging Options

Newer agents with activity against resistant Enterobacteriaceae are showing promise:

• Cefiderocol
• Eravacycline (for complicated intra-abdominal infections) 8

These treatment recommendations prioritize the most effective antimicrobials based on the most recent evidence to reduce morbidity, mortality, and improve quality of life in patients with E. cloacae UTIs.