What is the treatment for Klebsiella urinary tract infection (UTI)?

Treatment of Klebsiella Urinary Tract Infection

For Klebsiella UTI, treatment depends critically on infection severity and local resistance patterns: use a carbapenem (meropenem or imipenem) for severe/complicated infections with systemic symptoms, or consider fluoroquinolones, piperacillin-tazobactam, or oral agents for non-severe cases when local resistance is <10%. 1

Classification and Initial Assessment

The first step is determining whether the infection is uncomplicated or complicated, as this fundamentally changes management:

• Complicated UTI occurs with anatomic/functional urinary tract abnormalities, obstruction, foreign bodies, male sex, diabetes, immunosuppression, healthcare-associated infection, or multidrug-resistant organisms 1
• Klebsiella species are among the most common pathogens in complicated UTIs, along with E. coli, Proteus, Pseudomonas, Serratia, and Enterococcus 1
• Obtain urine culture and susceptibility testing before initiating therapy - this is mandatory for all Klebsiella UTIs to guide targeted treatment 1

Empiric Treatment for Severe/Complicated Klebsiella UTI

For Patients with Systemic Symptoms or Sepsis

Use combination therapy with:

• Amoxicillin plus an aminoglycoside, OR
• Second-generation cephalosporin plus an aminoglycoside, OR
• Intravenous third-generation cephalosporin 1

For confirmed third-generation cephalosporin-resistant Enterobacteriaceae (3GCephRE) including ESBL-producing Klebsiella:

• Carbapenem (imipenem or meropenem) is the recommended targeted therapy for bloodstream infections and severe infections (strong recommendation) 1
• For patients without septic shock, ertapenem may be used instead of imipenem/meropenem 1

For Complicated UTI Without Septic Shock

Alternative options include:

• Intravenous fosfomycin (strong recommendation, high-quality evidence) 1
• Aminoglycosides when active in vitro, for short durations 1
• Cotrimoxazole may be considered for non-severe complicated UTI (good practice statement) 1

Empiric Treatment for Non-Severe Klebsiella UTI

For Low-Risk, Non-Severe Infections

Consider antibiotic stewardship principles and use:

• Piperacillin-tazobactam
• Amoxicillin/clavulanic acid
• Quinolones (conditional recommendation) 1

Fluoroquinolone Use - Critical Restrictions

Only use ciprofloxacin or levofloxacin when:

• Local resistance rate is <10% 1
• Entire treatment can be given orally 1
• Patient does not require hospitalization 1
• Patient has anaphylaxis to β-lactam antimicrobials 1

Do NOT use fluoroquinolones for empirical treatment when:

• Patient is from urology department 1
• Patient has used fluoroquinolones in the last 6 months 1
• This restriction is critical given increasing fluoroquinolone resistance rates 2

Treatment Duration

Standard duration:

• 7 to 14 days generally recommended 1
• 14 days for men when prostatitis cannot be excluded 1
• Duration should be closely related to treatment of underlying urological abnormality 1

Shorter duration (7 days) may be considered when:

• Patient is hemodynamically stable 1
• Patient has been afebrile for at least 48 hours 1
• Short-course treatment is desirable due to relative contraindications to the antibiotic 1

Step-Down Therapy

Once patients are stabilized following carbapenem therapy:

• Transition to oral agents based on susceptibility: older β-lactam/β-lactamase inhibitors, quinolones, cotrimoxazole, or other antibiotics per susceptibility pattern 1
• This is good clinical practice and supports antimicrobial stewardship 1

Multidrug-Resistant Klebsiella

For ESBL-Producing Klebsiella

Treatment options for mild-moderate UTI:

• Nitrofurantoin
• Fosfomycin
• Fluoroquinolones (if susceptible)
• Cefoxitin
• Piperacillin-tazobactam
• Carbapenems (reserve for severe infections)
• Aminoglycosides 2

Alternatives to carbapenems may be used for mild-moderate UTIs based on susceptibility results 2

For Carbapenem-Resistant Klebsiella

Treatment options:

• Ceftazidime-avibactam
• Colistin
• Polymyxin B
• Fosfomycin
• Aztreonam
• Aminoglycosides
• Tigecycline 2

Important caveat: Tigecycline is NOT recommended for 3GCephRE infections (strong recommendation against use) 1

Critical Management Principles

Address underlying urological abnormalities:

• Optimal antimicrobial therapy alone is insufficient 1
• Management of obstruction, foreign bodies, or other complicating factors is mandatory 1

Avoid common pitfalls:

• Do NOT use cephamycins (cefoxitin, cefmetazole, flomoxef) or cefepime for 3GCephRE infections 1
• Reserve new β-lactam/β-lactamase inhibitors for extensively resistant bacteria due to stewardship considerations 1
• Do NOT treat asymptomatic bacteriuria, as this fosters resistance and increases recurrent UTI episodes 3

Therapeutic drug monitoring:

• Consider TDM for polymyxins, aminoglycosides, or carbapenems in severe CRGNB infections 1
• Particularly important for narrow therapeutic index drugs and in patients with organ dysfunction 1