What antibiotic would effectively treat a patient with a urinary tract infection (UTI) caused by Klebsiella pneumoniae, who also presents with bilateral lung involvement, suggestive of either pneumonia or pulmonary edema?

From the Guidelines

For a patient with a UTI caused by Klebsiella pneumoniae who also has bilateral lung infiltrates that could be pneumonia or pulmonary edema, I would recommend starting with a carbapenem, such as meropenem 1g IV every 8 hours, as it is effective against both urinary and respiratory infections caused by Klebsiella pneumoniae, including those producing extended-spectrum beta-lactamases (ESBLs) 1. This recommendation is based on the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for the treatment of infections caused by multidrug-resistant Gram-negative bacilli, which suggest using a carbapenem as targeted therapy for patients with severe infections due to third-generation cephalosporin-resistant Enterobacterales (3GCephRE) 1. Some key points to consider when treating this patient include:

• Obtaining cultures from both urine and sputum before starting antibiotics to guide targeted therapy once susceptibility results are available 1
• Monitoring renal function, particularly when using carbapenems or aminoglycosides, which can cause nephrotoxicity 1
• Providing supportive care, including oxygen therapy and fluid management, as needed 1
• Considering the use of an aminoglycoside, such as gentamicin or amikacin, in addition to a carbapenem, if the patient is critically ill or there is concern for resistant organisms 1
• Adjusting antibiotic selection based on local resistance patterns and susceptibility results 1

From the FDA Drug Label

Levofloxacin tablets are indicated for the treatment of nosocomial pneumonia due to methicillin-susceptible Staphylococcus aureus, Pseudomonas aeruginosa, Serratia marcescens, Escherichia coli, Klebsiella pneumoniae, Haemophilus influenzae, or Streptococcus pneumoniae. Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis Levofloxacin tablets are indicated for the treatment of uncomplicated urinary tract infections (mild to moderate) due to Escherichia coli, Klebsiella pneumoniae, or Staphylococcus saprophyticus.

Levofloxacin would be an appropriate antibiotic to treat both the UTI with Klebsiella pneumoniae and the possible pneumonia, as it is indicated for the treatment of both conditions. 2

• Key points:
  • Effective against Klebsiella pneumoniae
  • Indicated for nosocomial pneumonia and complicated urinary tract infections
  • Also indicated for uncomplicated urinary tract infections

From the Research

Treatment Options for UTI with Klebsiella pneumoniae

• The patient has a UTI with Klebsiella pneumoniae and also has bilateral past and lungs that could be pneumonia or pulmonary edema, requiring an antibiotic that can treat both conditions.
• Meropenem/vaborbactam is a carbapenem/β-lactamase inhibitor combination that has been approved for use in patients with complicated urinary tract infections (cUTIs), including pyelonephritis, and has shown excellent in vitro activity against Gram-negative clinical isolates, including KPC- and ESBL-producing Enterobacteriaceae 3.
• Aminoglycosides have been shown to be effective in treating CRKP UTI, with patients treated with aminoglycosides being less likely to fail therapy 4.
• Combined antibiotic therapy consisting of imipenem/cilastatin, gentamicin, and/or colistin, followed by oral fosfomycin, has been used to successfully treat UTIs caused by multiresistant K pneumoniae NDM-1 strains 5.
• The choice of antibiotic should be based on the susceptibility of the K. pneumoniae strain, as well as the patient's underlying medical conditions, such as chronic kidney disease 6.
• ESBL+ K. pneumoniae strains are associated with a higher mortality rate compared to ESBL- strains, highlighting the importance of early identification and adequate management of risk factors 7.

Antibiotic Resistance and Treatment

• K. pneumoniae strains can exhibit multidrug resistance, including resistance to carbapenems, making treatment challenging 4, 6.
• The use of meropenem/vaborbactam, aminoglycosides, and other antibiotics should be guided by susceptibility testing to ensure effective treatment 3, 4, 5.
• The development of antibiotic resistance is a major concern, and the use of antibiotics should be judicious and based on evidence-based guidelines 7.