From the Guidelines
For a patient with cellulitis and UTI transitioning from inpatient treatment with ceftazidime and daptomycin to outpatient care, two appropriate oral medication options would be trimethoprim-sulfamethoxazole (TMP-SMX) and doxycycline. TMP-SMX (Bactrim DS) can be prescribed at a dose of one double-strength tablet (160mg/800mg) twice daily for 5-7 days to address both the skin infection and urinary tract components, as recommended by the 2019 National Institute for Health and Care Excellence (NICE) guideline 1. Doxycycline 100mg twice daily for 5-7 days would be an alternative option with good coverage for both conditions, particularly for patients with nonpurulent cellulitis, as suggested by the American College of Physicians 1. The selection between these medications should consider the patient's culture results, antimicrobial susceptibilities, renal function, allergies, and medication interactions. These oral options provide reasonable coverage against common pathogens causing cellulitis (including Staphylococcus and Streptococcus species) and UTIs (including E. coli and other gram-negative organisms). If MRSA is a concern based on culture results or risk factors, TMP-SMX would be preferred, as it is effective against MRSA, according to the Infectious Diseases Society of America guidelines 1. For patients with impaired renal function, dose adjustments may be necessary. Follow-up within 2-3 days after discharge is recommended to ensure clinical improvement and address any potential adverse effects. It is also important to note that a 5- to 6-day course of antibiotics active against streptococci is recommended for patients with nonpurulent cellulitis, particularly for those able to self-monitor and who have close follow-up with primary care, as stated in the American College of Physicians guidelines 1.
From the FDA Drug Label
To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris
Two good outpatient oral medications to give the patient are:
- Trimethoprim-sulfamethoxazole for the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris 2 However, there is no information in the provided drug label about the treatment of cellulitis. Another option could be amoxicillin-clavulanate or clindamycin, but this information is not present in the provided label, and the patient is already on ceftazidime and daptomycin. Note: The choice of antibiotic should be based on culture and susceptibility results, and local epidemiology and susceptibility patterns. 2
From the Research
Outpatient Oral Medications for UTI and Cellulitis
For a patient with cellulitis and a UTI who is on ceftazidime and daptomycin inpatient, two good outpatient oral medications to consider are:
- Nitrofurantoin: This is a recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females 3, 4.
- Fosfomycin: This is another recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis, and it has been shown to have low resistance rates 3, 4, 5.
Key Considerations
When selecting outpatient oral medications, it's essential to consider the patient's specific needs and the susceptibility patterns of the causative organisms. The use of fluoroquinolones should be restricted due to increased rates of resistance 3, 4.
Alternative Options
Other alternative options for outpatient oral medications include:
- Amoxicillin-clavulanate: This can be used as a second-line option for UTIs, especially when combined with ceftibuten 6.
- Ceftibuten: This can be used in combination with amoxicillin-clavulanic acid for oral treatment of UTIs caused by ESBL-producing E. coli and K. pneumoniae 6. It's crucial to note that the choice of antibiotic should be guided by local susceptibility patterns and the patient's specific needs 3, 4.