Treatment of Klebsiella in Urinary Tract Infections
For Klebsiella UTIs, treatment should be based on antimicrobial susceptibility testing, with carbapenems recommended for severe infections caused by extended-spectrum β-lactamase (ESBL)-producing strains, while non-severe infections may be treated with aminoglycosides, fosfomycin, or susceptibility-guided oral options. 1, 2
Classification and Initial Approach
- Always obtain urine culture and susceptibility testing before initiating treatment for suspected Klebsiella UTI to guide antibiotic selection 2
- Classify the UTI as uncomplicated or complicated to determine the appropriate treatment approach 2
- Complicated UTIs occur in patients with underlying factors such as urological abnormalities, immunosuppression, diabetes, or healthcare-associated infections, and are more likely to be caused by antimicrobial-resistant Klebsiella strains 2
Treatment for Uncomplicated Klebsiella UTIs
For uncomplicated cystitis due to susceptible Klebsiella strains:
- Nitrofurantoin (if susceptible) for 5 days 2, 3
- Fosfomycin tromethamine 3g single dose 2, 3
- Trimethoprim-sulfamethoxazole (if susceptible) 4
- Fluoroquinolones (e.g., levofloxacin) should be avoided as empiric therapy if local resistance rates exceed 10% or if the patient has used fluoroquinolones in the last 6 months 2, 5
For uncomplicated pyelonephritis:
Treatment for Complicated Klebsiella UTIs
For complicated UTIs with systemic symptoms:
- Carbapenems (imipenem or meropenem) are recommended as targeted therapy for severe infections due to ESBL-producing Klebsiella 1, 2
- For non-severe infections, aminoglycosides or IV fosfomycin may be considered when active in vitro 1, 2
- For patients without septic shock, aminoglycosides can be used for short durations of therapy 1
For carbapenem-resistant Klebsiella (CRE) UTIs:
- For severe infections: meropenem-vaborbactam or ceftazidime-avibactam if active in vitro 1
- For non-severe infections: consider an old antibiotic chosen from among the in vitro active options (aminoglycosides, including plazomicin, are suggested over tigecycline for cUTI) 1, 3
- For CRE carrying metallo-β-lactamases or resistant to other options: cefiderocol is conditionally recommended 1
Treatment Duration
- Uncomplicated cystitis: 3-5 days 2
- Uncomplicated pyelonephritis: 7 days 2
- Complicated UTIs: 7-14 days 2
- Consider shorter treatment duration (7 days) when the patient is hemodynamically stable and has been afebrile for at least 48 hours 2
Special Considerations
ESBL-Producing Klebsiella
- For severe infections: carbapenems are the treatment of choice 2, 3
- For non-severe infections: nitrofurantoin, fosfomycin, or pivmecillinam (if susceptible) 3, 6
- High-dose amoxicillin-clavulanic acid (2875 mg amoxicillin/125 mg clavulanic acid twice daily) has shown promise in breaking resistance in select cases of ESBL-producing Klebsiella UTIs 7
Antimicrobial Stewardship Principles
- For patients with 3GCephRE (third-generation cephalosporin-resistant Enterobacterales) infections who have been stabilized, consider step-down targeted therapy using old β-lactam/β-lactamase inhibitors, quinolones, or cotrimoxazole based on susceptibility patterns 1
- Avoid using new β-lactam/β-lactamase inhibitor combinations for infections caused by 3GCephRE due to antibiotic stewardship considerations 1
- Aminoglycosides have shown good efficacy against Klebsiella species, including some resistant strains 2, 8
Monitoring and Follow-up
- Assess clinical response within 48-72 hours of initiating therapy 2
- If no improvement is seen, reassess diagnosis and consider alternative antimicrobial therapy based on culture results 2
- For recurrent Klebsiella UTIs, evaluate for underlying urological abnormalities or complicating factors 2
- In cases of highly resistant, recurrent ESBL-producing Klebsiella UTIs, novel approaches such as fecal microbiota transplantation may be considered in select cases 9