From the Guidelines
For patients with Chronic Kidney Disease (CKD) and complicated Urinary Tract Infections (UTIs), the recommended treatment is an intravenous third-generation cephalosporin as empirical treatment, or a combination of amoxicillin plus an aminoglycoside, or a second-generation cephalosporin plus an aminoglycoside, as stated in the 2024 European Association of Urology guidelines 1. When managing UTIs in CKD patients, it's crucial to consider the potential for antibiotic resistance and the need for dose adjustments due to impaired renal function.
- The treatment approach should prioritize managing any urological abnormality and/or underlying complicating factors, as emphasized in the guidelines 1.
- For patients with CKD, the use of ciprofloxacin and other fluoroquinolones should be avoided for empirical treatment of complicated UTIs, especially if the local resistance rate is ≥10% or if the patient has used fluoroquinolones in the last 6 months, as per the guidelines 1.
- The choice of antibiotic should be guided by urine culture results, and dose adjustments should be made according to the patient's renal function to minimize the risk of toxicity.
- Regular monitoring of kidney function during treatment is essential to prevent further kidney damage from either the infection or the medications used to treat it.
- In addition to antibiotic therapy, adequate hydration is important, but it must be balanced with fluid restrictions in advanced CKD to avoid exacerbating kidney function.
From the FDA Drug Label
1.9 Complicated Urinary Tract Infections: 5 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis 1.10 Complicated Urinary Tract Infections: 10 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections (mild to moderate) due to Enterococcus faecalis, Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, or Pseudomonas aeruginosa 1.11 Acute Pyelonephritis: 5 or 10 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia
The treatment for Urinary Tract Infections (UTI) in patients with Chronic Kidney Disease (CKD) is levofloxacin.
- The 5-day treatment regimen is indicated for complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis.
- The 10-day treatment regimen is indicated for complicated urinary tract infections due to Enterococcus faecalis, Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, or Pseudomonas aeruginosa.
- Acute pyelonephritis can be treated with a 5 or 10-day treatment regimen of levofloxacin, caused by Escherichia coli, including cases with concurrent bacteremia 2.
From the Research
Treatment of Urinary Tract Infections (UTI) in Patients with Chronic Kidney Disease (CKD)
The treatment of UTI in patients with CKD is based on the same principles as in patients with normal renal function, but with some considerations due to the increased risk of antimicrobial resistance and potential nephrotoxicity of certain antibiotics 3.
Antibiotic Treatment Options
- First-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis includes a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 4.
- Second-line options include oral cephalosporins, fluoroquinolones, and β-lactams, such as amoxicillin-clavulanate 4.
- For UTIs due to extended-spectrum β-lactamases (ESBLs)-producing Enterobacteriales, treatment options include nitrofurantoin, fosfomycin, pivmecillinam, fluoroquinolones, cefepime, piperacillin-tazobactam, and carbapenems 4.
- For UTIs caused by carbapenem-resistant Enterobacteriales (CRE), treatment options include ceftazidime-avibactam, meropenem/vaborbactam, imipenem/cilastatin-relebactam, colistin, fosfomycin, aztreonam, and cefiderocol 4.
Considerations in CKD Patients
- Drugs cleared by the kidney or by dialysis membranes need dose adjustment 3.
- Antimicrobials with potential systemic toxicity and nephrotoxicity should be administered with caution 3.
- The presence of multidrug-resistant (MDR) UTI is high in CKD patients, and choosing an appropriate antibiotic by urine culture and implementing a guideline on the rational use of antibiotics are essential to managing and preventing the development of MDR UTI 5.
Common Pathogens and Resistance Patterns
- Escherichia coli is the most common pathogen in UTI, followed by other gram-negative bacteria 3, 6, 5.
- Resistance to quinolones, penicillin, and aminoglycosides is common among gram-negative and gram-positive bacteria 4, 6, 5.
- Colistin Sulphate, Polymyxin B, Cefoxitin, Vancomycin, and Linezolid have high sensitivity against MDR UTI isolates 5.