What is the treatment approach for a patient with E. coli and lactobacillus in their urine who is currently taking Augmentin (amoxicillin-clavulanate)?

Treatment Approach for E. coli and Lactobacillus in Urine While on Augmentin

For a patient with E. coli and lactobacillus in urine who is currently taking Augmentin (amoxicillin-clavulanate), treatment should be continued only if the patient is symptomatic, with consideration for higher dosing if the infection is not responding to current therapy.

Assessment of Current Situation

Determine if Treatment is Needed

• Treatment is only indicated for symptomatic UTI 1
• Differentiate between colonization and true infection:
  • Pure growth of ≥50,000 CFUs/mL suggests true infection 1
  • Asymptomatic bacteriuria should not be treated 1

Evaluation of Current Therapy

• If the patient is already on Augmentin and still has E. coli in urine:
  • Check if the patient is symptomatic (dysuria, frequency, urgency)
  • Obtain a urine culture to determine antimicrobial susceptibility 1
  • Consider whether the current dosage is adequate

Treatment Options

Continuing Augmentin (Amoxicillin-Clavulanate)

For Susceptible E. coli:

• If E. coli is susceptible to Augmentin and symptoms are improving:
  • Continue current therapy to complete a 5-7 day course 1
  • Monitor for clinical response within 72 hours 1

For Potentially Resistant E. coli:

• Consider high-dose Augmentin if resistance is suspected:
  • Research shows high-dose amoxicillin with clavulanic acid can overcome resistance in some ESBL-producing organisms 2
  • Starting dosage of 2875 mg amoxicillin twice daily with 125 mg clavulanic acid twice daily has shown effectiveness 2
  • For severe infections, amoxicillin can be administered up to 18-30g IV daily in divided doses 1

Alternative Treatment Options

If Augmentin is ineffective or resistance is confirmed:

1. First-line alternatives 1:

   • Nitrofurantoin 100mg twice daily for 5 days (if GFR >30 mL/min)
   • Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days
   • Fosfomycin 3g as a single dose

2. For resistant organisms 1:

   • Ciprofloxacin 400mg twice daily (note increasing resistance)
   • Consider fluoroquinolones only when infection is caused by multidrug-resistant pathogens with no safe and effective alternative 3

Special Considerations

Regarding Lactobacillus

• Lactobacillus in urine is often considered a contaminant or colonizer rather than a pathogen
• Focus treatment on the E. coli, which is the more likely pathogenic organism
• If both organisms persist despite adequate therapy, consider urological evaluation for structural abnormalities

Monitoring and Follow-up

• Monitor clinical response within 72 hours of initiating or adjusting therapy 1
• Consider extending treatment duration if response is delayed 1
• Obtain follow-up urine culture after completion of therapy if symptoms persist

Caution with Fluoroquinolones

• Use fluoroquinolones only when no other effective options exist 3
• Inappropriate use is associated with increasing bacterial resistance 3
• Consider risks of musculoskeletal adverse events, especially in pediatric patients 3

Prevention of Recurrence

• Encourage adequate hydration (2-3L/day) 1
• Consider non-antimicrobial measures such as increased fluid intake and probiotics 1
• For frequent recurrences, consider prophylactic antibiotics after medical review 1