How do you treat pyelonephritis in a patient (pt) with Klebsiella pneumoniae and bacteremia?

Treatment of Pyelonephritis with Klebsiella pneumoniae and Bacteremia

For pyelonephritis with Klebsiella pneumoniae bacteremia, the most effective treatment is an initial intravenous antimicrobial regimen with ceftazidime/avibactam or meropenem/vaborbactam if carbapenem-resistant, or a fluoroquinolone, extended-spectrum cephalosporin, or carbapenem if susceptible, followed by targeted oral therapy based on susceptibility results. 1, 2

Initial Assessment and Treatment

• Obtain urine and blood cultures before initiating antibiotics to guide subsequent treatment 2
• For hospitalized patients with Klebsiella pneumoniae bacteremia, start with intravenous antimicrobial therapy 1, 2
• If carbapenem-resistant Klebsiella pneumoniae (CRKP) is suspected or confirmed:
  • Novel β-lactam agents such as ceftazidime/avibactam and meropenem/vaborbactam should be first-line treatment options 1
  • Imipenem/relebactam and cefiderocol may also be considered 1
• If susceptible to carbapenems, treatment options include:
  • Fluoroquinolones (ciprofloxacin 400mg IV every 8-12 hours) 1, 3
  • Extended-spectrum cephalosporins (cefepime 1-2g IV every 12 hours) 1, 4
  • Carbapenems 1, 2
  • Aminoglycosides (with or without another agent) 1, 2

Specific Antibiotic Recommendations

• For severe pyelonephritis with bacteremia, cefepime is FDA-approved for treatment of complicated urinary tract infections (including pyelonephritis) caused by Klebsiella pneumoniae 4
• Ciprofloxacin is indicated for urinary tract infections caused by Klebsiella pneumoniae, including cases with secondary bacteremia 3
• Duration of therapy:
  • 10-14 days for β-lactam agents 1, 2
  • 7 days for fluoroquinolones 1, 2

Antimicrobial Stewardship Considerations

• Perform antimicrobial susceptibility testing to guide therapy 2
• Consider therapeutic drug monitoring (TDM) when using polymyxins, aminoglycosides, or carbapenems for treatment of CRKP infections 1
• Fosfomycin-containing combination therapy may be considered for patients with CRE infection when the isolate is susceptible to fosfomycin 1
• Combination therapy with a cephalosporin and aminoglycoside has historically shown benefit in Klebsiella pneumoniae bacteremia 5

Special Considerations for Carbapenem-Resistant Klebsiella pneumoniae

• Rapid testing to identify specific carbapenemases is strongly recommended to guide antibiotic therapy 1
• For KPC-producing carbapenem-resistant Enterobacterales (CRE):
  • Ceftazidime/avibactam or meropenem/vaborbactam should be first-line treatment options 1
  • These newer agents have shown higher clinical cure rates and decreased mortality compared to traditional regimens 1

Monitoring and Follow-up

• Monitor renal function during treatment, as both the infection and certain antibiotics may affect kidney function 6
• Adjust therapy based on culture results once available 2
• Switch to appropriate oral therapy once the patient improves clinically and can tolerate oral intake 2
• For patients receiving aminoglycosides, TDM can optimize dosing, improve efficacy, and reduce nephrotoxicity 1

Common Pitfalls to Avoid

• Using oral β-lactams as monotherapy without an initial parenteral dose can lead to treatment failure 2
• Failing to consider local resistance patterns when selecting empiric therapy 2
• Delaying appropriate antibiotic therapy can lead to complications including renal scarring and end-stage renal disease 2
• Using aminoglycosides as monotherapy is not recommended due to nephrotoxicity risk 2
• Using nitrofurantoin or oral fosfomycin for pyelonephritis is not recommended due to insufficient data regarding efficacy 2