What is the recommended antibiotic regimen for a patient with a urinary tract infection (UTI) undergoing chemotherapy?

Antibiotic Recommendations for UTI in Patients Undergoing Chemotherapy

For patients undergoing chemotherapy with a urinary tract infection, fluoroquinolones (particularly levofloxacin 750 mg daily for 5 days) are recommended as first-line therapy due to their efficacy against a wide spectrum of uropathogens and favorable outcomes in immunocompromised patients. 1

Initial Assessment and Management

• Obtain urine culture before initiating antibiotics due to the increased likelihood of resistant organisms in immunocompromised patients 1
• Consider UTI in chemotherapy patients as a complicated UTI due to immunosuppression, which is a complicating factor 1
• If a urinary catheter has been in place for ≥2 weeks, replace it before starting antibiotics to improve treatment outcomes 1

First-Line Antibiotic Recommendations

Oral Therapy (for stable patients):

• Levofloxacin 750 mg once daily for 5 days - preferred regimen for patients who are not severely ill 1
• Ciprofloxacin 500-750 mg twice daily for 7 days (alternative if levofloxacin unavailable) 1
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days (if susceptibility confirmed) 1

Parenteral Therapy (for unstable or severely ill patients):

• Levofloxacin 750 mg IV once daily 1
• Ciprofloxacin 400 mg IV twice daily 1
• Ceftriaxone 1-2 g IV once daily 1
• Cefepime 1-2 g IV twice daily (good coverage for Pseudomonas) 1
• Piperacillin-tazobactam 3.375-4.5 g IV three times daily 1

Special Considerations for Chemotherapy Patients

• Consider broader spectrum initial therapy due to higher risk of resistant organisms in immunocompromised hosts 1
• For patients with neutropenia, use an antipseudomonal agent like cefepime, piperacillin-tazobactam, or a carbapenem 1
• Aminoglycosides (gentamicin 5 mg/kg daily or amikacin 15 mg/kg daily) can be considered for UTI but monitor renal function closely 1

Duration of Therapy

• 7 days for patients with prompt symptom resolution 1
• 10-14 days for patients with delayed response or severe infection 1
• 5-day course of levofloxacin (750 mg daily) has shown equivalent efficacy to longer courses in patients with mild-to-moderate infection 1, 2

For Multidrug-Resistant Organisms

• If carbapenem-resistant Enterobacterales (CRE) are suspected or confirmed:

  • Ceftazidime-avibactam 2.5 g IV every 8 hours 1
  • Meropenem-vaborbactam 4 g IV every 8 hours 1
  • Aminoglycosides may be effective for UTI caused by CRE 1

• If carbapenem-resistant Pseudomonas aeruginosa (CRPA) is suspected:

  • Ceftolozane-tazobactam 1.5-3 g IV every 8 hours 1
  • Ceftazidime-avibactam 2.5 g IV every 8 hours 1

Common Pitfalls to Avoid

• Avoid moxifloxacin for UTI due to uncertainty regarding effective urinary concentrations 1
• Don't use fluoroquinolones if local resistance rates exceed 10% 1
• Don't treat asymptomatic bacteriuria in catheterized patients unless they are undergoing urologic procedures 1
• Avoid unnecessary broad-spectrum antibiotics when narrower options are available based on culture results to prevent resistance 1
• Don't forget to adjust therapy based on culture and susceptibility results 1

Follow-up Recommendations

• Adjust therapy based on culture results and clinical response 1
• Consider extending treatment and urologic evaluation if fever persists beyond 72 hours 1
• For recurrent UTIs in chemotherapy patients, consider prophylaxis after discussion with oncology team 1