What antibiotic treats Pseudomonas (Pseudomonas aeruginosa) urinary tract infection (UTI)?

Antibiotics for Pseudomonas Aeruginosa UTI

For Pseudomonas aeruginosa urinary tract infections, fluoroquinolones (ciprofloxacin or levofloxacin) are the first-line oral treatment options, while newer β-lactam agents such as ceftolozane/tazobactam and ceftazidime/avibactam are the preferred options for difficult-to-treat resistant strains. 1, 2, 3

First-Line Treatment Options

Oral Treatment

• Ciprofloxacin 500-750 mg twice daily for 7-14 days (depending on complexity of infection) 3, 4
• Levofloxacin 750 mg once daily for 5-10 days (depending on complexity of infection) 2, 1

Parenteral Treatment (for hospitalized patients)

• Ciprofloxacin 400 mg twice daily 1
• Levofloxacin 750 mg once daily 1
• Cefepime 1-2 g twice daily 1
• Piperacillin/tazobactam 2.5-4.5 g three times daily 1
• Aminoglycosides (gentamicin 5 mg/kg daily or amikacin 15 mg/kg daily) 1

Treatment for Resistant Pseudomonas (DTR-PA)

For difficult-to-treat resistant Pseudomonas aeruginosa (DTR-PA), defined as strains non-susceptible to standard antipseudomonal antibiotics: 1

• Ceftolozane/tazobactam 1.5-3 g IV every 8 hours (first-line option) 1
• Ceftazidime/avibactam 2.5 g IV every 8 hours (first-line option) 1
• Imipenem/cilastatin/relebactam 1.25 g IV every 6 hours (alternative option) 1
• Colistin-based therapy (alternative option when other agents are not available) 1

Duration of Treatment

• Uncomplicated UTI: 7 days 1
• Complicated UTI: 7-14 days (14 days for men when prostatitis cannot be excluded) 1
• Treatment should be tailored once culture and susceptibility results are available 1

Important Considerations

• Fluoroquinolone resistance should be <10% in the local population for these agents to be used empirically 1
• Monotherapy with a highly microbiologically active antipseudomonal agent is generally preferred over combination therapy 1
• Combination therapy may be considered on a case-by-case basis for difficult-to-treat resistant strains, especially with consultation from infectious disease specialists 1
• Fosfomycin may be considered as a companion agent in combination regimens for resistant strains 1

Pitfalls and Caveats

• Fluoroquinolones have an FDA advisory warning about disabling and serious adverse effects, and should be used with caution 1
• Rapid emergence of resistance to ciprofloxacin can occur, particularly with Pseudomonas aeruginosa 4, 5
• Carbapenems and novel broad-spectrum antimicrobial agents should only be considered in patients with confirmed multidrug-resistant organisms 1
• Pseudomonas aeruginosa has a remarkable capacity to develop resistance to commonly used antibiotics 1
• Always obtain urine culture and susceptibility testing to guide definitive therapy 1

Treatment Algorithm

1. Obtain urine culture and susceptibility testing before starting antibiotics if possible 1
2. For empiric oral therapy in non-severe cases: Ciprofloxacin or levofloxacin (if local resistance <10%) 3, 2
3. For empiric IV therapy in severe/hospitalized cases: Cefepime, piperacillin/tazobactam, or a fluoroquinolone 1
4. For confirmed resistant strains: Use newer β-lactam/β-lactamase inhibitor combinations (ceftolozane/tazobactam or ceftazidime/avibactam) 1
5. Adjust therapy based on culture results and clinical response 1
6. Complete appropriate duration based on infection complexity 1