What alternative antibiotic can be used to treat a Group B streptococcal (Strep B) urinary tract infection (UTI) in a patient with a penicillin allergy?

From the Guidelines

For a strep B (Group B Streptococcus) UTI in a patient with penicillin allergy, clindamycin is typically the first-line alternative, usually dosed at 900 mg IV every 8 hours until delivery, as recommended by the CDC guidelines 1.

Considerations for Treatment

When considering treatment options for a patient with a penicillin allergy, it's crucial to weigh the severity of the allergy, the severity of the infection, and local resistance patterns.

• Clindamycin is a suitable alternative for patients with severe penicillin allergies, as it inhibits bacterial protein synthesis and has been shown to be effective against Group B Streptococcus 1.
• Vancomycin is another option for more severe infections, administered intravenously, and is recommended for patients with a history of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of penicillin or a cephalosporin 1.
• For patients with non-severe penicillin allergies, cephalosporins like ceftriaxone or cefuroxime might be considered, though there is a small risk of cross-reactivity, as noted in studies on antibiotic therapy for acute otitis media 1.

Importance of Diagnosis Confirmation

Before starting treatment, it's essential to confirm the diagnosis with a urine culture and sensitivity testing to ensure the selected antibiotic will be effective against the specific strain of Group B Streptococcus.

• This approach allows for targeted therapy, reducing the risk of antibiotic resistance and ensuring the best possible outcomes for the patient.
• The CDC guidelines emphasize the importance of proper diagnosis and treatment to prevent early-onset Group B Streptococcal disease 1.

From the FDA Drug Label

Clindamycin is also indicated in the treatment of serious infections due to susceptible strains of streptococci, pneumococci, and staphylocci Its use should be reserved for penicillin-allergic patients or other patients for whom, in the judgment of the physician, a penicillin is inappropriate. For a strep B UTI in a patient allergic to penicillin, clindamycin can be considered as an alternative antibiotic option, as it is indicated for the treatment of serious infections caused by susceptible strains of streptococci, including strep B. However, bacteriologic studies should be performed to determine the causative organisms and their susceptibility to clindamycin. The use of clindamycin should be reserved for cases where a penicillin is inappropriate, and the physician should consider the nature of the infection and the suitability of less toxic alternatives 2.

From the Research

Antibiotic Options for Strep B UTI in Penicillin-Allergic Patients

• For patients with a penicillin allergy, alternative antibiotics must be considered for the treatment of strep B UTI.
• According to 3, beta-lactam antibiotics may be used safely for patients with unknown or possible penicillin allergy, but penicillins or beta-lactams should not be used for patients with hives or anaphylactic reactions.
• Studies 4 and 5 suggest that cefazolin and vancomycin are commonly prescribed for intrapartum neonatal sepsis prophylaxis in GBS positive patients with penicillin allergies.

First-Generation Cephalosporins as Alternative Options

• First-generation cephalosporins, such as cephalexin, have been shown to be effective in treating uncomplicated lower urinary tract infections (uLUTIs) due to non-extended-spectrum beta-lactamase-producing Enterobacteriaceae 6.
• Cefazolin, a first-generation cephalosporin, exhibits high susceptibility for uropathogens commonly implicated in cases of uncomplicated UTI and may be a suitable alternative to ceftriaxone for inpatient treatment of UTIs, with a lower risk of hospital-onset Clostridioides difficile infection (HOCDI) 7.

Considerations for Antibiotic Selection

• When selecting an antibiotic for a penicillin-allergic patient with a strep B UTI, clinicians should consider the severity of the allergy, the susceptibility of the organism, and the potential risks and benefits of different antibiotic options.
• Antibiotic susceptibility testing should be performed to guide antibiotic selection, as recommended by 4.