What is an appropriate antibiotic choice for an afebrile patient on Rinvoq (upadacitinib) with a suspected urinary tract infection?

Antibiotic Selection for Afebrile Patient on Rinvoq with Suspected UTI

For an afebrile patient on Rinvoq (upadacitinib) with a suspected urinary tract infection, amoxicillin-clavulanic acid, nitrofurantoin, or sulfamethoxazole-trimethoprim are the most appropriate first-line antibiotic choices, with nitrofurantoin being preferred due to lower resistance rates. 1, 2

Rationale for Antibiotic Selection

Patient-Specific Considerations

1. Immunosuppression status:

   • Rinvoq (upadacitinib) is a JAK inhibitor that causes immunosuppression
   • Immunosuppression is a complicating factor for UTIs 1
   • This classifies the patient as having a complicated UTI

2. Afebrile status:

   • Absence of fever suggests lower UTI rather than pyelonephritis
   • Allows for oral antibiotic therapy rather than parenteral treatment

First-Line Options

Preferred options (in order):

1. Nitrofurantoin 100mg twice daily for 5 days

   • High efficacy for lower UTI
   • Low resistance rates compared to other options
   • Minimal impact on normal flora
   • Good safety profile 1, 2

2. Sulfamethoxazole-trimethoprim 160/800mg twice daily for 3-5 days

   • Effective for uncomplicated UTIs
   • Consider only if local resistance rates are <20% 1
   • May have higher resistance rates (up to 34% in some studies) 3

3. Amoxicillin-clavulanic acid

   • Recommended by WHO Essential Medicines guidelines 1
   • Generally high susceptibility rates for urinary E. coli 1

Second-Line Options

If first-line options cannot be used due to allergies, resistance, or other contraindications:

1. Fosfomycin trometamol 3g single dose

   • Minimal resistance
   • Convenient single-dose administration 2

2. Ciprofloxacin or other fluoroquinolones

   • Should be reserved for cases where first-line options cannot be used
   • Only use if local resistance rates are <10% 1
   • Avoid if patient has used fluoroquinolones in the last 6 months 1
   • Note FDA warnings about serious side effects affecting tendons, muscles, joints, and nervous system 1

Treatment Duration

• For complicated UTIs in immunosuppressed patients: 7-14 days of treatment is recommended 1
• The shorter duration (7 days) may be considered if the patient remains afebrile and clinically improves 1

Follow-up Recommendations

1. Obtain urine culture before starting antibiotics to guide therapy if initial empiric treatment fails 2
2. No routine follow-up urine culture is necessary if symptoms resolve 2
3. Repeat urine culture if symptoms persist despite treatment 2

Important Caveats

• Local antibiogram patterns should guide antibiotic selection whenever possible
• Avoid fluoroquinolones as empiric therapy due to increasing resistance and risk of adverse effects
• Consider extended treatment duration (7 days minimum) due to the patient's immunosuppressed status
• Monitor for drug interactions between antibiotics and Rinvoq, though significant interactions are uncommon with the recommended first-line agents