What are the treatment options for a urinary tract infection (UTI) caused by a Gram-negative rod in a patient with an allergy to Cipro (ciprofloxacin) and Sulfa (sulfonamides)?

From the Guidelines

For a urinary tract infection (UTI) caused by gram-negative rods in a patient allergic to both ciprofloxacin and sulfa drugs, I recommend nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) as the first-line treatment option. This recommendation is based on the guidelines provided by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases, which suggest that nitrofurantoin is an appropriate choice for therapy due to minimal resistance and propensity for collateral damage, with efficacy comparable to 3 days of trimethoprim-sulfamethoxazole 1.

Some key points to consider when treating UTIs caused by gram-negative rods in patients with allergies to ciprofloxacin and sulfa drugs include:

• The importance of choosing an antibiotic with minimal resistance and low propensity for collateral damage
• The need to consider local resistance rates of uropathogens when selecting an empirical treatment
• The availability of alternative treatment options, such as fosfomycin trometamol (3 g in a single dose) or pivmecillinam (400 mg bid for 3–7 days), although these may have inferior efficacy compared to standard short-course regimens 1
• The potential use of beta-lactam agents, including amoxicillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil, in 3–7-day regimens, although these generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials 1

It's also important to note that fluoroquinolones, such as ciprofloxacin, should be reserved for important uses other than acute cystitis due to their propensity for collateral damage 1. Additionally, amoxicillin or ampicillin should not be used for empirical treatment given their relatively poor efficacy and high prevalence of antimicrobial resistance worldwide 1.

Overall, the choice of antibiotic should be guided by the most recent and highest-quality evidence, with consideration of the patient's specific allergies and the local resistance patterns of uropathogens. Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is a safe and effective option for patients with gram-negative rod UTIs who are allergic to ciprofloxacin and sulfa drugs, as supported by the guidelines and evidence 1.

From the Research

Treatment Options for Gram-Negative Rod UTI

• For patients allergic to cipro and sulfa, alternative treatment options for Gram-negative rod UTI include:
  • Nitrofurantoin 2, 3
  • Fosfomycin 2, 3, 4
  • Amoxicillin-clavulanate 2, 3
  • Piperacillin-tazobactam 2, 3
  • Carbapenems, such as meropenem 2, 3, 5
  • Ceftazidime-avibactam 2, 3, 4
  • Ceftolozane-tazobactam 2, 3, 4
  • Aminoglycosides, such as plazomicin 3, 4

Resistance Patterns

• Resistance to common antibiotics, such as amoxicillin, trimethoprim, and ciprofloxacin, is increasing among Gram-negative rods causing UTI 6
• Meropenem has been shown to have a broad spectrum of activity against Gram-positive and Gram-negative pathogens, including ESBL- and AmpC-producing Enterobacteriaceae 5

Considerations for Treatment

• The choice of treatment should be based on local susceptibility patterns and the severity of the infection 2, 3
• An interdisciplinary approach, including urologists, microbiologists, and infectious disease physicians, is recommended to ensure prudent use of antibiotics and avoid the development of resistance 4