What is the best oral antibiotic for a complicated urinary tract infection (UTI) in a patient with end-stage renal disease (ESRD)?

From the Guidelines

For complicated UTIs in patients with end-stage renal disease (ESRD), oral trimethoprim-sulfamethoxazole (TMP-SMX) DS tablet every 24 hours is often the best oral antibiotic choice, if the organism is susceptible, due to its efficacy and relatively favorable pharmacokinetics in patients with renal impairment 1. When considering oral antibiotic options for complicated UTIs in ESRD patients, it's crucial to weigh the benefits and risks of each medication, taking into account the patient's renal function, potential drug interactions, and local resistance patterns.

• Key considerations include:
  • The susceptibility of the uropathogen to the chosen antibiotic
  • The need for dosage adjustments based on renal function
  • The potential for adverse effects, such as hyperkalemia with TMP-SMX
  • The importance of monitoring drug levels and adjusting doses as needed to avoid toxicity
• According to the European Association of Urology guidelines, a combination of antibiotics, such as amoxicillin plus an aminoglycoside, or a second-generation cephalosporin plus an aminoglycoside, may be recommended for complicated UTIs, but these regimens often require intravenous administration and may not be suitable for oral treatment 1.
• Ciprofloxacin, a fluoroquinolone, may be considered for oral treatment of complicated UTIs in ESRD patients, but its use is generally recommended only when the local resistance rate is <10% and the patient does not require hospitalization 1.
• Ultimately, antibiotic selection should be guided by culture and sensitivity results, and consultation with infectious disease and nephrology specialists is advisable to optimize therapy while considering the patient's dialysis schedule and residual renal function.

From the FDA Drug Label

Adults with Impaired Renal Function: Ciprofloxacin is eliminated primarily by renal excretion; however, the drug is also metabolized and partially cleared through the biliary system of the liver and through the intestine. These alternative pathways of drug elimination appear to compensate for the reduced renal excretion in patients with renal impairment Nonetheless, some modification of dosage is recommended, particularly for patients with severe renal dysfunction. The following table provides dosage guidelines for use in patients with renal impairment: RECOMMENDED STARTING AND MAINTENANCE DOSES FOR PATIENTS WITH IMPAIRED RENAL FUNCTION Creatinine Clearance (mL/min)Dose

50 See Usual Dosage 30-50 250-500 mg q 12 h 5-29 250-500 mg q 18 h Patients on hemodialysis or Peritoneal dialysis 250-500 mg q 24 h (after dialysis)

The best oral antibiotic for complicated UTI with ESRD is Ciprofloxacin.

• For patients with creatinine clearance of 5-29 mL/min, the recommended dose is 250-500 mg q 18 h.
• For patients on hemodialysis or Peritoneal dialysis, the recommended dose is 250-500 mg q 24 h (after dialysis) 2.

From the Research

Complicated UTI Treatment in ESRD Patients

• The treatment of complicated urinary tract infections (UTIs) in patients with end-stage renal disease (ESRD) requires careful consideration of antibiotic selection and dosing.
• According to a study published in 1987 3, oral ciprofloxacin was found to be effective in treating complicated UTIs in elderly patients, including those with ESRD.
• The study demonstrated that ciprofloxacin was able to eradicate the infection in 84% of patients, with a relapse rate of 16% at one week post-therapy.
• Another study published in 2006 4 discussed the use of ciprofloxacin extended release in the treatment of UTIs, highlighting its efficacy and safety profile.

Antibiotic Selection in ESRD Patients

• A 2021 study 5 investigated antibiotic prescribing patterns in ESRD patients in New York State, finding that ESRD patients were more likely to receive antibiotics than non-ESRD patients.
• The study also found that trimethoprim-sulfamethoxazole was commonly prescribed, but often at elevated doses that were not adjusted for renal function.
• A separate study published in 2021 6 examined antibiotic prescribing patterns for UTIs in emergency department and urgent care settings, finding that fluoroquinolones were frequently prescribed, but with opportunities for improvement in treatment duration and antimicrobial choice.

Considerations for Oral Antibiotic Selection

• When selecting an oral antibiotic for complicated UTI in ESRD patients, considerations should include the patient's renal function, the severity of the infection, and the potential for antibiotic resistance.
• Ciprofloxacin, as discussed in the studies 4, 3, may be a suitable option for some patients, but its use should be guided by local resistance patterns and patient-specific factors.
• Other antibiotics, such as trimethoprim-sulfamethoxazole, may also be considered, but with careful attention to dosing and potential side effects in patients with ESRD.