From the Guidelines
For a patient presenting with glycosuria, ketonuria, hematuria, proteinuria, positive nitrate test, and leukocyturia, I strongly recommend empiric treatment with a fluoroquinolone or a cephalosporin as the first-line option for the apparent urinary tract infection, specifically pyelonephritis, as indicated by the European Association of Urology guidelines 1. The presence of glycosuria and ketonuria suggests uncontrolled diabetes, which requires immediate attention and management alongside the antibiotic treatment. The positive nitrate test and leukocyturia strongly suggest a bacterial infection, likely from gram-negative organisms.
- Key considerations in managing this patient include:
- Obtaining a urine culture to confirm the infection and guide therapy if the empiric treatment fails 1
- Evaluating the patient for diabetic ketoacidosis given the high glucose and ketones
- Implementing blood glucose monitoring, insulin therapy, and fluid management alongside the antibiotic treatment
- Considering the potential for kidney damage from either the infection or poorly controlled diabetes, with follow-up urinalysis after treatment to ensure resolution
- The choice of antibiotic should be based on local resistance patterns and optimized, with fluoroquinolones and cephalosporins being the recommended options for oral empiric treatment of uncomplicated pyelonephritis 1.
- It is crucial to promptly differentiate between uncomplicated and potentially obstructive pyelonephritis, as the latter can swiftly progress to urosepsis, using appropriate imaging techniques as recommended by the European Association of Urology guidelines 1.
From the FDA Drug Label
The following in vitro data are available, but their clinical significance is unknown: Levofloxacin exhibits in vitro minimum inhibitory concentrations (MIC values) of 2 mcg/mL or less against most (≥ 90%) isolates of the following microorganisms; Gram-Negative Bacteria Escherichia coli Klebsiella pneumoniae Proteus mirabilis Pseudomonas aeruginosa
A report of Susceptible indicates that the pathogen is likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable
- Levofloxacin is indicated for the treatment of bacterial infections, including those caused by Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa.
- The presence of glycosuria, ketonuria, hematuria, proteinuria, positive nitrate test, and leukocyturia suggests a possible urinary tract infection (UTI), which may be caused by one of the aforementioned bacteria.
- Levofloxacin may be effective in treating UTIs caused by these bacteria, as it has shown in vitro activity against them 2.
- However, it is essential to note that the clinical significance of this in vitro data is unknown, and the effectiveness of levofloxacin in treating UTIs should be determined on a case-by-case basis.
- Trimethoprim-sulfamethoxazole may also be considered as an alternative treatment option for UTIs, but its effectiveness in this specific case is not directly supported by the provided drug label information 3.
From the Research
Indicated Antibiotics for Urinary Tract Infections
The patient's symptoms, including glycosuria, ketonuria, hematuria, proteinuria, positive nitrate test, and leukocyturia, suggest a complicated urinary tract infection (UTI). The following antibiotics are indicated for treatment:
- Nitrofurantoin 4
- Fosfomycin tromethamine 4
- Pivmecillinam 4
- Ciprofloxacin 5, 6, 7, 8
- Trimethoprim-sulfamethoxazole 4, 6, 7, 8
- Levofloxacin 5
- Amoxicillin-clavulanate 4
- Cefepime 4
- Piperacillin-tazobactam 4
- Carbapenems 4
- Ceftazidime-avibactam 4
- Ceftolozane-tazobactam 4
- Aminoglycosides, including plazomicin 4
- Cefiderocol 4
- Colistin 4
- Aztreonam 4
- Tigecycline 4
Considerations for Antibiotic Resistance
When selecting an antibiotic, it is essential to consider the patient's history of antibiotic use, recent travel, and local resistance patterns. The patient's prior use of fluoroquinolones, such as ciprofloxacin, may increase the risk of resistance 7. Additionally, being born outside the United States may also increase the risk of resistance to certain antibiotics, such as trimethoprim-sulfamethoxazole 7.
Treatment Options for Specific Types of UTIs
The following treatment options are available for specific types of UTIs:
- UTIs due to AmpC-β-lactamase-producing Enterobacteriales: nitrofurantoin, fosfomycin, pivmecillinam, fluoroquinolones, cefepime, piperacillin-tazobactam, and carbapenems 4
- UTIs due to ESBL-E coli: nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 4
- UTIs due to ESBL-Klebsiella pneumoniae: pivmecillinam, fosfomycin, finafloxacin, and sitafloxacin 4
- UTIs due to carbapenem-resistant Enterobacteriales (CRE): ceftazidime-avibactam, meropenem/vaborbactam, imipenem/cilastatin-relebactam, colistin, fosfomycin, aztreonam, and ceftazidime-avibactam, aztreonam, and amoxicillin-clavulanate, aminoglycosides, including plazomicin, cefiderocol, tigecycline 4
- UTIs due to multidrug-resistant (MDR)-Pseudomonas spp.: fluoroquinolones, ceftazidime, cefepime, piperacillin-tazobactam, carbapenems, including imipenem-cilastatin/relebactam, meropenem, and fosfomycin, ceftolozane-tazobactam, ceftazidime-avibactam, aminoglycosides, including plazomicin, aztreonam, and ceftazidime-avibactam, cefiderocol, and colistin 4