What alternative antibiotic can be prescribed for a woman with a urinary tract infection (UTI) and costovertebral angle (CVA) tenderness who cannot tolerate Bactrim (trimethoprim/sulfamethoxazole)?

Alternative Antibiotics for UTI with CVA Tenderness in a Patient Unable to Tolerate Bactrim

For a woman with a UTI and CVA tenderness who cannot tolerate Bactrim, a fluoroquinolone such as ciprofloxacin or levofloxacin is recommended as the first-line alternative, provided local resistance rates are below 10%. 1

Assessment of Severity

The presence of costovertebral angle (CVA) tenderness suggests upper urinary tract involvement (pyelonephritis), which requires more aggressive treatment than uncomplicated cystitis:

• CVA tenderness, along with fever, rigors, flank pain, or systemic symptoms indicates complicated UTI or pyelonephritis 1
• This condition requires broader antimicrobial coverage and potentially longer treatment duration 1

First-Line Alternative Treatment Options

Oral Treatment (for hemodynamically stable patients)

If the patient is stable enough for outpatient management:

• Fluoroquinolones (if local resistance rates <10%):
  • Ciprofloxacin 500-750 mg twice daily for 7 days 1
  • Levofloxacin 750 mg once daily for 5 days 1, 2
  • Consider only if the patient has not used fluoroquinolones in the last 6 months 1

Parenteral Treatment (for more severe cases)

If the patient requires hospitalization:

• Third-generation cephalosporins:
  • Ceftriaxone 1-2 g daily 1
  • Cefotaxime 2 g three times daily 1
• Aminoglycosides:
  • Gentamicin 5 mg/kg daily 1
  • Amikacin 15 mg/kg daily 1

Treatment Duration

• For pyelonephritis (UTI with CVA tenderness): 7-14 days of treatment is generally recommended 1
• Duration can be shortened to 7 days when the patient has been afebrile for at least 48 hours 1

Special Considerations

Antimicrobial Resistance

• Local resistance patterns should guide empiric therapy 1, 3
• Fluoroquinolone resistance is increasing globally, particularly in the Asia-Pacific region 4, 5
• If local fluoroquinolone resistance exceeds 10%, consider alternative agents or initial IV therapy 1

Alternative Options for Patients with Multiple Allergies

For patients who cannot tolerate both Bactrim and fluoroquinolones:

• Nitrofurantoin 100 mg four times daily (for uncomplicated lower UTI only, not for pyelonephritis) 1, 3
• Fosfomycin 3 g single dose (for uncomplicated lower UTI only, not for pyelonephritis) 1, 3
• Cephalosporins (if no cross-reactivity with sulfa allergy):
  • Oral: Cefpodoxime 200 mg twice daily for 10 days 1
  • Oral: Ceftibuten 400 mg daily for 10 days 1

Follow-up Recommendations

• Obtain urine culture before initiating treatment to guide therapy 1
• Consider imaging (ultrasound or CT) if symptoms worsen or fail to improve after 72 hours of appropriate therapy 1
• Adjust therapy based on culture results and clinical response 1

Common Pitfalls to Avoid

• Do not use nitrofurantoin or oral fosfomycin for pyelonephritis as they do not achieve adequate tissue concentrations in the upper urinary tract 1, 3
• Do not use fluoroquinolones if the patient has used them in the past 6 months due to increased risk of resistance 1
• Do not treat for too short a duration with pyelonephritis, as this can lead to treatment failure and recurrence 1

In conclusion, for a woman with UTI and CVA tenderness who cannot tolerate Bactrim, fluoroquinolones are the preferred alternative if local resistance rates are low. For more severe cases or areas with high fluoroquinolone resistance, parenteral therapy with third-generation cephalosporins or aminoglycosides is recommended.