From the Guidelines
No, cefoxitin should not be used as the first-line treatment for an ESBL urinary tract infection (UTI) that is resistant to cefepime and ceftriaxone but sensitive to cefoxitin, due to limited clinical experience and concerns about antibiotic stewardship. According to the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines 1, for patients with low-risk, non-severe infections due to third-generation cephalosporin-resistant Enterobacterales (3GCephRE), piperacillin-tazobactam, amoxicillin/clavulanic acid, or quinolones may be considered under the consideration of antibiotic stewardship. The guidelines also suggest that cephamycins, such as cefoxitin, should not be used for 3GCephRE infections due to limited evidence and concerns about promoting resistance 1. Instead, carbapenems, such as imipenem or meropenem, are recommended as targeted therapy for patients with bloodstream infections (BSI) and severe infections due to 3GCephRE 1. For patients with non-severe UTIs, aminoglycosides or IV fosfomycin may be conditionally recommended when active in vitro for short durations of therapy 1. It is essential to consider the susceptibility pattern of the isolate and the severity of the infection when selecting an antibiotic regimen, and to prioritize antibiotic stewardship to minimize the risk of promoting resistance. In this case, while cefoxitin may be active against the ESBL-producing organism in vitro, its use is not recommended due to the availability of more effective and evidence-based treatment options.
From the Research
Treatment of ESBL UTIs with Cefoxitin
- Cefoxitin can be used to treat urinary tract infections (UTIs) caused by Extended-Spectrum Beta-Lactamase (ESBL)-producing Enterobacteriaceae, including ESBL-producing Escherichia coli (ESBL-EC) 2, 3.
- Studies have shown that cefoxitin has a strong in vitro activity against ESBL-producing Enterobacteriaceae and can be an alternative treatment to carbapenems for UTIs caused by these organisms 2, 3.
- A prospective monocentric cohort study found that cefoxitin was effective in treating UTIs caused by ESBL-EC, with a good tolerance and a high microbiological cure rate 2.
- Pharmacological studies have determined that cefoxitin can reach pharmacological targets in the treatment of ESBL-EC pyelonephritis, but administration modalities should be optimized according to MICs 3.
Considerations for Using Cefoxitin
- The effectiveness of cefoxitin in treating ESBL UTIs may depend on the MIC of the organism and the patient's renal function 4, 3.
- High doses of cefoxitin may be necessary to achieve the desired pharmacological targets, especially in patients with normal renal function 4.
- The emergence of cephamycin-resistance is a concern when using cefoxitin to treat ESBL UTIs, and therapeutic drug monitoring may be useful to minimize this risk 4.
- Cefoxitin may not be effective in treating UTIs caused by ESBL-producing Enterobacteriaceae that are resistant to cefoxitin, and alternative treatments should be considered in these cases 5.
Alternative Treatment Options
- Other treatment options for ESBL UTIs include carbapenems, such as meropenem and imipenem, as well as other beta-lactam antibiotics, such as piperacillin-tazobactam and ceftazidime-avibactam 5.
- Oral combination treatments, such as cefixime and amoxicillin/clavulanate, may also be effective in treating ESBL UTIs 6.
- The choice of treatment should be based on the susceptibility pattern of the organism and the patient's clinical condition, as well as local resistance patterns and treatment guidelines 5.