What to do for a patient taking Jardiance (empagliflozin) with recurrent Urinary Tract Infections (UTIs)?

Management of Recurrent UTIs in Patients Taking Jardiance (Empagliflozin)

When a patient on Jardiance develops recurrent UTIs, first treat each acute episode with culture-guided, first-line antibiotics (nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin), then implement non-antimicrobial prevention strategies before considering either antimicrobial prophylaxis or discontinuation of Jardiance. 1, 2

Immediate Management of Acute UTI Episodes

Diagnostic Approach

• Obtain urine culture and antimicrobial susceptibility testing before starting antibiotics for each symptomatic episode 3, 1
• Do not treat asymptomatic bacteriuria—this fosters antimicrobial resistance and increases recurrence 3, 1
• Evaluate for signs of serious infection: fever, back pain, nausea/vomiting, or systemic symptoms that may indicate pyelonephritis or urosepsis 2

First-Line Antibiotic Treatment

• Nitrofurantoin 100 mg twice daily for 5 days 3, 1
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (if local resistance <20%) 3, 1
• Fosfomycin trometamol 3 g single dose 3, 1
• Treat for no longer than 7 days to minimize resistance development 3, 1

Critical Warning About Jardiance and Serious UTIs

The FDA label specifically warns that serious urinary tract infections requiring hospitalization have occurred with SGLT2 inhibitors like Jardiance 2. One case report documented septic shock from Serratia marcescens pyelonephritis in a patient on empagliflozin 4. If your patient develops fever, flank pain, or systemic symptoms, consider temporarily discontinuing Jardiance and treat aggressively 2.

Prevention Strategies: Stepwise Approach

Step 1: Non-Antimicrobial Interventions (Try First)

• Increase fluid intake to reduce UTI risk 3, 1
• Vaginal estrogen replacement for postmenopausal women (strong recommendation) 3, 1
• Immunoactive prophylaxis (strong recommendation) 3, 1
• Methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 3, 1
• Consider cranberry products or D-mannose, though evidence is weak and contradictory 3, 1
• Probiotics containing strains proven for vaginal flora regeneration 3

Step 2: Antimicrobial Prophylaxis (If Non-Antimicrobial Measures Fail)

After discussing risks and benefits with the patient, prescribe one of the following 3, 1:

Daily prophylaxis options:

• Nitrofurantoin 50-100 mg daily 3
• Trimethoprim-sulfamethoxazole 40/200 mg daily 3
• Cephalexin 125-250 mg daily 3

Alternative dosing:

• Fosfomycin 3 g every 10 days 3
• Post-coital prophylaxis (same agents, single dose after intercourse) 3

Duration: 6-12 months with periodic reassessment 3. Some patients continue for years without adverse events, though this lacks evidence-based support 3.

Step 3: Consider Discontinuing Jardiance

If UTIs persist despite prophylaxis, weigh the cardiovascular and renal benefits of Jardiance against the morbidity of recurrent infections 2. The mechanism of SGLT2 inhibitors (inducing glucosuria) creates a favorable environment for bacterial growth 5. While one study showed only a slight increase in UTI risk with dapagliflozin (another SGLT2 inhibitor), serious infections including urosepsis have been reported 5, 4.

Discontinue Jardiance if:

• Patient develops pyelonephritis or urosepsis 2, 4
• Recurrent UTIs continue despite antimicrobial prophylaxis
• Quality of life is significantly impaired by infections 1

Common Pitfalls to Avoid

• Do not perform routine surveillance urine cultures or cystoscopy in women under 40 without risk factors 3
• Do not treat asymptomatic bacteriuria—this is a strong recommendation that prevents resistance 3, 1
• Do not use fluoroquinolones or broad-spectrum antibiotics as first-line therapy unless culture results dictate otherwise 3, 6, 7
• Do not continue antibiotics beyond 7 days for acute cystitis 3, 1
• Do not ignore warning signs of serious infection (fever >38°C, flank pain, systemic symptoms) that require immediate evaluation and possible Jardiance discontinuation 2

Special Considerations

Antibiotic Adverse Effects

• Nitrofurantoin carries extremely low risk of pulmonary (0.001%) and hepatic (0.0003%) toxicity 3
• Fluoroquinolones increase risk of tendinopathies and aortic aneurysms—avoid unless necessary 3
• All antibiotics carry risk of gastrointestinal symptoms and vaginitis 3

Self-Administered Therapy

For patients with good compliance and ability to recognize symptoms early, consider self-administered short-term antibiotic therapy (strong recommendation) 3, 1. Provide a prescription for first-line antibiotics to start at symptom onset, with instructions to obtain urine culture before treatment.