How do you treat Enterobacter cloacae (a type of bacteria) in the urine?

Treatment of Enterobacter cloacae in Urine

For Enterobacter cloacae urinary tract infections, carbapenems (meropenem or imipenem) are the recommended first-line treatment due to high resistance rates to other antibiotics. 1

Antibiotic Selection Algorithm

First-line options:

• Carbapenems: Meropenem or Imipenem
  • Dosing: Meropenem 1g IV every 8 hours or Imipenem 500mg IV every 6 hours
  • Duration: 7-14 days (14 days for men when prostatitis cannot be excluded) 1

Alternative options (if susceptibility confirmed):

• Fourth-generation cephalosporins: Cefepime

  • Dosing: 1-2g IV every 12 hours 2
  • For severe infections: 2g IV every 12 hours 2

• Fluoroquinolones (if susceptible): Ciprofloxacin

  • Dosing: 500mg PO twice daily 3
  • Only if susceptibility is confirmed by culture

For carbapenem-resistant E. cloacae:

• Combination therapy: 1
  • Polymyxins (colistin)
  • Tigecycline
  • Fosfomycin
  • Double carbapenem regimen

Important Considerations

Resistance Patterns

E. cloacae has high intrinsic resistance to many antibiotics, particularly:

• First and second-generation cephalosporins (ineffective) 1
• Third-generation cephalosporins (not recommended due to increased likelihood of resistance) 1
• Ampicillin and amoxicillin-clavulanate (high resistance rates) 4

Clinical Assessment

• Determine if the infection is complicated or uncomplicated
• Assess for signs of systemic infection (fever, chills, hemodynamic instability)
• Evaluate for underlying urological abnormalities that may require intervention 1

Laboratory Testing

• Always obtain urine culture and susceptibility testing before starting therapy
• Adjust empiric therapy based on culture results
• Consider blood cultures if signs of systemic infection are present

Special Situations

Asymptomatic Bacteriuria

• Do not treat asymptomatic bacteriuria except in:
  • Pregnant women
  • Patients undergoing urologic procedures with mucosal trauma 1
  • Pre-operative orthopedic implant surgery (controversial) 1

Complicated UTI

For complicated UTI (presence of structural abnormalities, immunosuppression, or healthcare-associated infections): 1

• Longer treatment duration (14 days)
• Consider urological evaluation for anatomical abnormalities
• Source control is essential (drainage of obstructions, removal of foreign bodies)

Catheter-Associated UTI

• Remove or change catheter if possible
• Treat for 7 days if prompt resolution of symptoms
• Treat for 10-14 days for delayed response 1

Monitoring and Follow-up

• Clinical reassessment after 48-72 hours
• If no improvement, reevaluate diagnosis and consider:
  • Resistant organism
  • Inadequate source control
  • Alternative diagnosis

Prevention

• Address underlying urological abnormalities
• Avoid unnecessary catheterization
• Implement infection control measures to prevent spread of resistant strains 5

E. cloacae has been associated with outbreaks in healthcare settings, particularly related to contaminated equipment such as ureteroscopes 5. Proper sterilization of urological equipment is essential to prevent such outbreaks.

Remember that E. cloacae has a high potential for developing resistance during therapy, so susceptibility testing and appropriate antibiotic selection are crucial for successful treatment.