Is ertapenem (a carbapenem antibiotic) suitable for a female patient with Chronic Kidney Disease (CKD), a nephrostomy (urinary diversion) tube, and a Urinary Tract Infection (UTI)?

Ertapenem Use in Female Patient with CKD, Nephrostomy Tube, and UTI

Ertapenem is suitable for a female patient with CKD and nephrostomy tube with UTI, but requires dose adjustment to 500 mg daily for patients with severe renal impairment (creatinine clearance ≤30 mL/min/1.73 m²), with careful monitoring for neurotoxicity. 1

Indications and Dosing

• Ertapenem is FDA-approved for complicated urinary tract infections (cUTIs) including pyelonephritis due to Escherichia coli or Klebsiella pneumoniae 1
• Standard dosing for adults with normal renal function is 1 gram IV once daily for 10-14 days 1
• For patients with severe renal impairment (creatinine clearance ≤30 mL/min/1.73 m²), the dose should be reduced to 500 mg daily 1
• For patients on hemodialysis, a supplementary dose of 150 mg is recommended if ertapenem is administered within 6 hours prior to hemodialysis 1

Considerations for Patients with CKD

• Patients with advanced CKD are at increased risk of ertapenem-induced neurotoxicity, even when receiving renally-adjusted doses 2
• Neurotoxicity can manifest as hallucinations, asterixis, myoclonic jerks, cognitive impairment, and peripheral neuropathy 3
• Neurotoxicity may persist for up to 2 weeks after discontinuation of ertapenem in patients with Stage 5 CKD 3
• Close monitoring for neurological symptoms is essential when using ertapenem in patients with advanced CKD 2

Alternative Options for cUTIs in CKD with Multidrug-Resistant Organisms

If the UTI is caused by carbapenem-resistant Enterobacteriaceae (CRE), consider:

1. Ceftazidime-avibactam 2.5g IV q8h (with dose adjustment for renal function) 4
2. Meropenem-vaborbactam 4g IV q8h (with dose adjustment for renal function) 4
3. Imipenem-cilastatin-relebactam 1.25g IV q6h (with dose adjustment for renal function) 4
4. Plazomicin 15 mg/kg IV q12h (with dose adjustment for renal function) 4
5. Single-dose aminoglycoside (for simple cystitis only) 4

Empiric Treatment Recommendations for cUTIs

If local resistance patterns are unknown and empiric therapy is needed:

• For hospitalized patients with systemic symptoms, recommended options include: 4

  • Amoxicillin plus an aminoglycoside
  • A second-generation cephalosporin plus an aminoglycoside
  • An intravenous third-generation cephalosporin

• Carbapenems (including ertapenem) are recommended for hospitalized patients with pyelonephritis requiring intravenous antimicrobial therapy 4

Special Considerations for Patients with Nephrostomy Tubes

• Patients with nephrostomy tubes have complicated UTIs by definition, requiring longer treatment courses (7-14 days) 4
• The presence of a nephrostomy tube increases the risk of infection with resistant organisms 4
• Urine culture and susceptibility testing are essential to guide targeted therapy 4
• Management of the urological abnormality (proper nephrostomy tube care) is mandatory alongside antimicrobial therapy 4

Monitoring and Follow-up

• Monitor renal function and neurological symptoms closely during ertapenem therapy 2, 3
• Consider urine culture after completion of therapy if symptoms persist or recur 4
• No routine post-treatment urinalysis or urine cultures are indicated for asymptomatic patients 4

Caveats and Pitfalls

• Despite FDA-approved dose adjustment recommendations, ertapenem may still cause neurotoxicity in patients with advanced CKD even at reduced doses 2, 3
• Ertapenem has restricted activity against nosocomial pathogens such as Pseudomonas aeruginosa and Acinetobacter species 5
• Consider local resistance patterns when selecting empiric therapy; if fluoroquinolone resistance exceeds 10%, fluoroquinolones should be avoided 4
• Patients with nephrostomy tubes may be colonized with multidrug-resistant organisms, requiring broader empiric coverage until culture results are available 6