In an adult with a urinary tract infection caused by Staphylococcus epidermidis (susceptible to nitrofurantoin, tetracycline, linezolid, vancomycin; resistant to benzylpenicillin), are levofloxacin (Levaquin) and metronidazole (Flagyl) adequate coverage?

Levofloxacin and Metronidazole Are Inadequate for Staphylococcus epidermidis UTI

Levofloxacin and metronidazole will NOT provide adequate coverage for this Staphylococcus epidermidis urinary tract infection. Metronidazole has no activity against staphylococci, and while levofloxacin has some anti-staphylococcal activity, the culture shows superior alternatives that should be used instead 1, 2.

Why This Regimen Fails

Metronidazole Coverage Gap

• Metronidazole is exclusively an anti-anaerobic agent with activity against Bacteroides fragilis and other obligate anaerobes 1
• It has zero activity against aerobic gram-positive cocci including all Staphylococcus species 1
• Metronidazole is recommended only for intra-abdominal infections requiring anaerobic coverage, not for urinary tract infections caused by staphylococci 1

Levofloxacin Limitations

• While levofloxacin demonstrates activity against S. epidermidis in research studies, with most strains susceptible 2, 3, fluoroquinolone resistance in staphylococci is a significant concern 4, 5
• Fluoroquinolone resistance rates have reached 98% in MRSA urinary isolates in some populations 4
• The IDSA guidelines recommend avoiding fluoroquinolones as first-line therapy due to increasing resistance concerns 6

Recommended Treatment Based on Susceptibility Results

Use nitrofurantoin as first-line therapy for this uncomplicated UTI caused by S. epidermidis 1, 4.

Rationale for Nitrofurantoin

• Your culture shows susceptibility to nitrofurantoin (MIC ≤16 µg/mL) 1
• Nitrofurantoin demonstrates only 2.7% resistance rates against MRSA urinary isolates 4
• For catheter-associated UTI, a 7-day course is recommended after catheter removal 1
• For women aged ≥65 years with CA-UTI without upper tract symptoms after catheter removal, a 3-day regimen may be considered 1

Alternative Options Based on Your Susceptibilities

Linezolid (600 mg PO/IV q12h):

• Your isolate is susceptible (MIC 1 µg/mL) 7
• Linezolid shows effectiveness for VRE urinary tract infections despite limited urinary excretion 7
• Standard duration: 7-14 days for most CA-UTI 1

Tetracycline/Doxycycline:

• Your isolate is susceptible (MIC ≤1 µg/mL)
• Reasonable alternative for staphylococcal UTI 1

Vancomycin (if severe illness or bacteremia):

• Your isolate is susceptible (MIC 4 µg/mL) 1, 4
• Reserved for systemically ill patients or those requiring IV therapy 4
• 100% sensitivity demonstrated for MRSA urinary isolates requiring parenteral therapy 4

Critical Clinical Pitfalls to Avoid

Do Not Continue Current Regimen

• Continuing levofloxacin plus metronidazole wastes the metronidazole component entirely and relies solely on levofloxacin, which is not optimal given available alternatives 1

Assess for Complicated vs. Uncomplicated UTI

• If this is simple cystitis after catheter removal: use nitrofurantoin 3-7 days 1
• If patient has delayed response, upper tract involvement, or remains catheterized: extend to 7-14 days 1
• If patient has pyelonephritis or systemic illness: consider IV vancomycin or linezolid 1, 4

Consider Source Control

• If catheter remains in place, removal or replacement is essential for treatment success 1
• Persistent bacteriuria despite appropriate antibiotics suggests need for catheter management 1