What is the preferred antibiotic for a patient with a urinary tract infection (UTI) due to Providencia stuartii, which is resistant to co-amoxiclav (Co-amoxicillin), in a nursing home setting with elevated C-reactive protein (CRP) levels, requiring administration via Percutaneous Endoscopic Gastrostomy (PEG) tube?

From the Guidelines

Ciprofloxacin administered via PEG is the preferred option for this nursing home patient with a UTI caused by Providencia stuartii resistant to co-amoxiclav. The patient's high CRP of 350 indicates significant inflammation, and with the organism showing resistance to the current treatment, prompt change is necessary. Although the provided evidence 1, 2 does not directly address the treatment of Providencia stuartii infections, ciprofloxacin is generally preferred for infections caused by gram-negative organisms due to its broad-spectrum activity and ability to achieve high urinary concentrations.

When considering the options, it's essential to note that:

• Fosfomycin and nitrofurantoin are also sensitive options, but ciprofloxacin is generally preferred for Providencia infections due to better clinical outcomes.
• The provided evidence 1, 2 focuses on the treatment of infections due to multidrug-resistant organisms, including recommendations for enterococcal infections and VRE bacteremia, but does not specifically address Providencia stuartii.
• Ciprofloxacin 500mg twice daily for 7 days would be an appropriate treatment regimen, as it has excellent bioavailability when administered through a PEG tube.

To maximize the effectiveness of ciprofloxacin, it's crucial to:

• Ensure the PEG tube is flushed before and after medication administration
• Temporarily hold enteral feeding for 1-2 hours around ciprofloxacin doses to maximize absorption
• Monitor the patient's response to treatment and adjust the regimen as necessary to minimize the risk of complications and improve outcomes.

From the FDA Drug Label

Ciprofloxacin tablets, USP are indicated for the treatment of infections caused by susceptible strains of the designated microorganisms in the conditions and patient populations listed below. Skin and Skin Structure Infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Proteus mirabilis, Proteus vulgaris, Providencia stuartii, Morganella morganii, Citrobacter freundii, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus aureus methicillin-susceptible Staphylococcus epidermidis, or Streptococcus pyogenes Urinary Tract Infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, Providencia rettgeri, Morganella morganii, Citrobacter diversus, Citrobacter freundii, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus epidermidis, Staphylococcus saprophyticus, or Enterococcus faecalis

The preferable option is ciprofloxacin because it is indicated for the treatment of urinary tract infections caused by Providencia stuartii 3.

From the Research

Treatment Options for Providencia Stuartii Infection

The patient has been diagnosed with a Providencia stuartii infection, which is resistant to co-amoxiclav but sensitive to ciprofloxacin, fosfomycin, and nitrofurantoin. Given the need for administration via PEG, the following options are available:

• Ciprofloxacin: a fluoroquinolone antibiotic that has been shown to be effective against Providencia stuartii 4, 5
• Fosfomycin: an antibiotic that has been used to treat urinary tract infections, including those caused by Providencia stuartii 4, 5, 6
• Nitrofurantoin: an antibiotic that is commonly used to treat urinary tract infections, including those caused by Providencia stuartii 4, 5

Considerations for Treatment

When choosing a treatment option, it is essential to consider the patient's condition and the potential for antibiotic resistance. Providencia stuartii is known to be resistant to multiple antibiotics, making treatment challenging 7. The use of switch therapy, where the patient is switched from parenteral to non-parenteral antibiotic administration, may be an option 8. However, this approach requires close collaboration between healthcare professionals and careful monitoring of the patient's condition.

Antibiotic Resistance

The studies suggest that Providencia stuartii is often resistant to multiple antibiotics, including co-amoxiclav 4, 5, 7. The use of ciprofloxacin, fosfomycin, and nitrofurantoin may be effective in treating the infection, but it is crucial to monitor the patient's response to treatment and adjust the antibiotic regimen as needed. The COVID-19 pandemic may have contributed to the increased resistance of Enterobacteriaceae, including Providencia stuartii, to certain antibiotics 4.