What antibiotics are recommended for a urinary tract infection (UTI) with suspected renal calculi (kidney stones) and flank pain?

From the Guidelines

For a urinary tract infection (UTI) with suspected renal calculus and flank pain, empiric antibiotic therapy with a third-generation cephalosporin, such as ceftriaxone 1g intravenously, is recommended as the initial treatment. This approach is based on the most recent guidelines from the European Association of Urology 1, which emphasize the importance of covering for potential complications and resistance patterns in complicated UTIs. The choice of antibiotic should be guided by local resistance patterns and patient-specific factors, such as allergy history and severity of symptoms.

Key considerations in managing UTIs with suspected renal calculus include:

• Obtaining a urine culture before starting antibiotics, if possible, to guide targeted therapy 1
• Using a third-generation cephalosporin as empirical treatment for complicated UTI with systemic symptoms 1
• Avoiding the use of ciprofloxacin and other fluoroquinolones for empirical treatment of complicated UTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months 1
• Managing any urological abnormality and/or underlying complicating factors 1

Pain management is also crucial, typically with NSAIDs like ibuprofen 400-600 mg every 6-8 hours as needed. Adequate hydration (2-3 liters of water daily) is essential to help flush bacteria from the urinary tract and potentially assist with stone passage. Patients should seek immediate medical attention if they develop fever over 101°F, severe pain uncontrolled by oral medications, persistent vomiting, or inability to urinate, as these may indicate complications requiring hospitalization.

From the FDA Drug Label

1. 9 Complicated Urinary Tract Infections: 5 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis
2. 10 Complicated Urinary Tract Infections: 10 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections (mild to moderate) due to Enterococcus faecalis, Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, or Pseudomonas aeruginosa
3. 11 Acute Pyelonephritis: 5 or 10 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia 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

Levofloxacin and trimethoprim-sulfamethoxazole can be used to treat complicated urinary tract infections.

• Levofloxacin is indicated for the treatment of complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis, Enterobacter cloacae, or Pseudomonas aeruginosa.
• Trimethoprim-sulfamethoxazole is indicated for the treatment of urinary tract infections due to susceptible strains of Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris. However, the presence of renal calculus and flank pain may indicate a more severe infection, such as pyelonephritis, which may require more aggressive treatment. In this case, levofloxacin may be a suitable option, as it is indicated for the treatment of acute pyelonephritis caused by Escherichia coli. It is essential to consult the FDA drug label 2 and 3 for the most up-to-date information on the use of these antibiotics.

From the Research

Antibiotics for UTI with Suspected Renal Calculus and Flank Pain

• The treatment of urinary tract infections (UTIs) with suspected renal calculus and flank pain requires careful consideration of the underlying cause and potential antibiotic resistance 4, 5.
• For patients with acute pyelonephritis, which is a bacterial infection of the kidney and renal pelvis, urine culture with antimicrobial susceptibility testing should be performed to direct therapy 5.
• Fluoroquinolones and trimethoprim/sulfamethoxazole are effective oral antibiotics in most cases, but increasing resistance makes empiric use problematic 5.
• When local resistance to a chosen oral antibiotic likely exceeds 10%, one dose of a long-acting broad-spectrum parenteral antibiotic should also be given while awaiting susceptibility data 5.
• Patients with a history of kidney stones may have an increased likelihood of resistance to certain antibiotics, such as nitrofurantoin 6.
• In cases of concurrent urinary tract obstruction, referral for urgent decompression should be pursued 5.

Considerations for Antibiotic Choice

• The choice of antibiotic should be based on the severity of the infection, the presence of underlying medical conditions, and the potential for antibiotic resistance 4, 7.
• For uncomplicated UTIs, oral antibiotics such as nitrofurantoin, fosfomycin, or pivmecillinam may be effective 4.
• For more complicated UTIs, such as those caused by extended-spectrum beta-lactamase (ESBL)-producing organisms, parenteral antibiotics such as piperacillin-tazobactam or carbapenems may be necessary 4.
• The use of ciprofloxacin extended release may be an effective option for treating UTIs, particularly in cases where patient compliance is a concern 7.