Treatment Duration for MDR Organism Cystitis
For patients with simple cystitis due to multidrug-resistant organisms (MDROs), a single-dose aminoglycoside is recommended as the preferred treatment approach. 1
Treatment Options Based on Organism Type
Carbapenem-Resistant Enterobacterales (CRE) Cystitis
- Single-dose aminoglycoside is recommended for simple cystitis due to CRE (Weak recommendation, very low quality of evidence) 1
- For uncomplicated urinary tract infections due to vancomycin-resistant enterococci (VRE), a single dose of fosfomycin 3g PO is recommended 1
- Alternative options for VRE cystitis include nitrofurantoin 100 mg PO every 6 hours 1
Treatment Duration Considerations
- For simple cystitis caused by MDROs, shorter treatment durations are preferred to minimize antimicrobial resistance development 1
- For recurrent UTI patients experiencing acute cystitis episodes, treatment should be as short as reasonable, generally no longer than seven days 1
- When treating with oral agents for MDR cystitis, the duration should be individualized based on antimicrobial susceptibility testing results and clinical response 1, 2
Specific Antimicrobial Options
First-line Options for MDR Cystitis
- Fosfomycin: A single 3g oral dose for uncomplicated MDR cystitis 1, 3
- Nitrofurantoin: 100 mg PO every 6 hours (duration based on clinical response) 1, 4
- Aminoglycosides: Single-dose therapy for simple cystitis due to CRE 1
For Complicated UTIs due to MDROs
- Ceftazidime-avibactam 2.5 g IV q8h is recommended for complicated UTIs caused by CRE 1
- Meropenem-vaborbactam 4 g IV q8h or imipenem-cilastatin-relebactam 1.25 g IV q6h are recommended for complicated UTIs caused by CRE 1
- Plazomicin 15 mg/kg IV q12h is recommended for complicated UTIs due to CRE 1
Clinical Pearls and Caveats
- Infectious disease consultation is highly recommended in the management of infections caused by MDROs 1
- Antimicrobial susceptibility testing is essential to guide clinicians in selecting appropriate antimicrobial agents for MDRO infections 1
- Avoid surveillance urine testing, including urine culture, in asymptomatic patients with recurrent UTIs 1
- Do not treat asymptomatic bacteriuria in non-pregnant patients 1
- When treating MDR UTIs, consider local resistance patterns and optimize therapy based on culture results 1, 2
Special Considerations
- For patients with MDR cystitis who cannot tolerate first-line treatments, consider alternative regimens such as fosfomycin 3g every 48 or 72 hours for a total of 3 doses 3
- For patients with recurrent UTIs experiencing acute cystitis episodes associated with urine cultures resistant to oral antibiotics, culture-directed parenteral antibiotics may be used for as short a course as reasonable 1
- Carbapenems and novel broad-spectrum antimicrobial agents should only be considered in patients with early culture results indicating the presence of multidrug-resistant organisms 1
Remember that the treatment approach should be guided by antimicrobial susceptibility testing results, and the duration should be as short as possible while ensuring clinical cure to minimize the development of further resistance.