Switch it up a little - antibiotic preference for UTI/pyelo

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EctopicFetus

EctopicFetus

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Favorite antibiotic for uncomplicated cystitis and Pyelo. Bonus for reason why.
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Nitrofurantoin for uncomplicated per CDC guidelines (unless history of renal insufficiency).

Cefuroxime or cefdinir for pyelo.

Have you asked your facility for its urine culture antibiogram data to see what resistance is in your community?
 
Locally bactrim has a 30% resistance with e coli so we don’t use that.
 
xaelia said:
3 days of trimethoprim for uncomplicated UTI around here.

Pyelonephritis is cephalexin.
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Just trimethoprim without the sulfamethoxazole? I don’t think I’ve ever seen trimethoprim by itself, but i know you’re over in New Zealand.

Side rant, just saw my 4th case of SJS/TENS secondary to tmp/smx in my career and I just don’t understand why it is so commonly prescribed given all the terrible, life threatening complications we see from it. During residency I had a 35 yo with TENS with 99% BSA involvement die a slow and painful death in the burn ICU after getting it rx’d for asymptomatic bacteriuria. I’ve seen countless acute renal failure cases from it and marked hyperkalemia. Seen a case of aplastic anemia from it, as well. It is, by far, the outpatient antibiotic I see most commonly causing life threatening complications. It has probably accounted for more such complications I’ve seen in my career compared to all other outpatient antibiotics combined.

Obviously I’m pretty biased, but I treat it the way most EM docs treat fluoroquinolones (which I also rarely rx).
 
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Zebra Hunter said:
Just trimethoprim without the sulfamethoxazole? I don’t think I’ve ever seen trimethoprim by itself, but i know you’re over in New Zealand.

Side rant, just saw my 4th case of SJS/TENS secondary to tmp/smx in my career and I just don’t understand why it is so commonly prescribed given all the terrible, life threatening complications we see from it. During residency I had a 35 yo with TENS with 99% BSA involvement die a slow and painful death in the burn ICU after getting it rx’d for asymptomatic bacteriuria. I’ve seen countless acute renal failure cases from it and marked hyperkalemia. Seen a case of aplastic anemia from it, as well. It is, by far, the outpatient antibiotic I see most commonly causing life threatening complications. It has probably accounted for more such complications I’ve seen in my career compared to all other outpatient antibiotics combined.

Obviously I’m pretty biased, but I treat it the way most EM docs treat fluoroquinolones (which I also rarely rx).
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You're not EM... You're.... Inf.dis?
 
Two of the three cases of SJS I’ve seen were due to Bactrim, one of whom died at a young age during my residency training in the ICU. Scarred me as well. I almost never use Bactrim unless last remaining option.

I’ve seen a lot of treatment failure and bounce backs with Macrobid. Not great for elderly and those with CKD.

High rates of resistance to E. Coli for Cipro in my area.

Cephalexin for UTI/cystitis and longer course with more frequent dosing for pyelo has worked well for me. Penicillin cross allergy nonexistent. Keflex seems to work great for all comers in my area and simplifies prescribing.

Intrigued by idea of using other generation Cephalosporins for pyelo if others have good reasons or data to share.
 
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Mount Asclepius said:
Two of the three cases of SJS I’ve seen were due to Bactrim, one of whom died at a young age during my residency training in the ICU. Scarred me as well. I almost never use Bactrim unless last remaining option.

I’ve seen a lot of treatment failure and bounce backs with Macrobid. Not great for elderly and those with CKD.

High rates of resistance to E. Coli for Cipro in my area.

Cephalexin for UTI/cystitis and longer course with more frequent dosing for pyelo has worked well for me. Penicillin cross allergy nonexistent. Keflex seems to work great for all comers in my area and simplifies prescribing.

Intrigued by idea of using other generation Cephalosporins for pyelo if others have good reasons or data to share.
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Yeah, my case in residency is something I’ll never forget. She showed up already with about 30% BSA involvement, two days after symptom onset and about 3-4 days after starting bactrim. She had pharyngeal involvement and presented with stridor. We couldn’t bag her because anytime we tried to get a seal, more skin would slough off her face. Luckily got the tube in fine, but then she continued to deteriorate and spent the entire month of the rotation trying to keep her alive.

And I don’t really like cephalexin for pyelo due to the QID dosing which can be difficult to get patients to stick to especially when you’re asking them to take it for 10-14 days. I frequently will rx cefpodoxime (3rd generation) for pyelo and complicated UTIs.
 
Zebra Hunter said:
Yeah, my case in residency is something I’ll never forget. She showed up already with about 30% BSA involvement, two days after symptom onset and about 3-4 days after starting bactrim. She had pharyngeal involvement and presented with stridor. We couldn’t bag her because anytime we tried to get a seal, more skin would slough off her face. Luckily got the tube in fine, but then she continued to deteriorate and spent the entire month of the rotation trying to keep her alive.

And I don’t really like cephalexin for pyelo due to the QID dosing which can be difficult to get patients to stick to especially when you’re asking them to take it for 10-14 days. I frequently will rx cefpodoxime (3rd generation) for pyelo and complicated UTIs.
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10-14 days? Da fuq? 5-7 days up in here.

I generally prefer macrobid for lower uti in young people. Sometimes use cephalexin, although beat lactams aren't my preferred agent due to lower cure rates compared to other classes. Basically never use tmp-smx for UTIs unless for some reason there's a culture already back. I've been known to give a 1 time dose of IM gentamycin for complicated lower UTIs as well. I usually use a 3rd gen cephalosporin or cipro for (true) pyelo. I don't like extrapolating to the sensitivity of E. coli to 1st gen cephs to the higher probability of other gram negs in actually ill patients.

A few other thoughts:
--the way to avoid complications from abx is not to avoid certain classes due to rare side effects, but to consider whether or not abx are truly indicated. I would estimate that at least 3/4 of Rx's for UTIs are unnecessary due to mis/overdiagnosis. Adverse anecdotes are level IV data...
--disagree with the overly pedantic recommendation to 'know your hospital's antibiogram'. Susceptabilities derived from gomatose nursing home patients and post-op ICU patients are of little use in deciding on antibiotics for healthy patients from the community. I do however always check the patient's Rx history and prior culture results to inform my decision making
 
turkeyjerky said:
10-14 days? Da fuq? 5-7 days up in here.

I generally prefer macrobid for lower uti in young people. Sometimes use cephalexin, although beat lactams aren't my preferred agent due to lower cure rates compared to other classes. Basically never use tmp-smx for UTIs unless for some reason there's a culture already back. I've been known to give a 1 time dose of IM gentamycin for complicated lower UTIs as well. I usually use a 3rd gen cephalosporin or cipro for (true) pyelo. I don't like extrapolating to the sensitivity of E. coli to 1st gen cephs to the higher probability of other gram negs in actually ill patients.

A few other thoughts:
--the way to avoid complications from abx is not to avoid certain classes due to rare side effects, but to consider whether or not abx are truly indicated. I would estimate that at least 3/4 of Rx's for UTIs are unnecessary due to mis/overdiagnosis. Adverse anecdotes are level IV data...
--disagree with the overly pedantic recommendation to 'know your hospital's antibiogram'. Susceptabilities derived from gomatose nursing home patients and post-op ICU patients are of little use in deciding on antibiotics for healthy patients from the community. I do however always check the patient's Rx history and prior culture results to inform my decision making
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You’re only giving 5-7 days of keflex for pyelo? The literature is generally pretty scant on antibiotic duration, but almost everyone recommends 10-14 days if using cephalosporins.

As for abx complications, IMO, you absolutely should consider rare side effects when rx’ing. Why risk the 1/1000 chance of SJS/TENS, acute renal failure, or aplastic anemia (all complications without effective treatments and potentially deadly) when there are numerous effective alternatives for UTIs? This is precisely the reasoning why fluoroquinolones fell out of favor and their first line recommendation has been limited to very specific indications now. I still rx bactrim and fluoroquinolones occasionally, but if I have an effective and safe alternative, it doesn’t make a lot of sense for myself to prescribe them.
 
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Almost all of our urine flora are now resistant to Fluoroquinolones. I am still shocked that this is the primary medication started by many of our MLPs and primary care offices. Typically, Keflex for uncomplicated UTI with no culture.
 
Keflex for most UTIs unless I have a culture that shows cefazolin resistance, it doesn’t penetrate ureter or renal parenchyma as well so 10 days in anybody who isn’t simply dysuria or suprapubic pain. If anything systemic like nausea, fevers, low back or flank pain I’m doing 1 days up to 14 days. I have looked with our pharmacist a few times and seen different dosing frequencies, our local practice is 500 mg BID. I’ve done TID for 10 days for flank pain and UTI (no stone obv) on occasion based on something I saw on UpToDate awhile back but usually I’ll just extend BID to 14 days if they seem reliable. If im at all concerned they may not go that full timeframe, I’ll do cefdinir or cefpodoxime for 7 days. The difference between these two is what my EMR thinks their insurance will cover. My preference is 200 mg bid cefpodoxime, I think this was in idsa for pyelo maybe something about penetrates parenchyma a bit better than cefdinir but I think they both do decently. I rarely use macrobid, creat clearance on my patients sucks too much it seems. Only use Bactrim in skin and soft tissue with recorded mrsa hx or allergy to doxy. Rarely for UTI, almost only in male with concern for prostatitis that has cx with cipro/levofloxacin resistance in the past. If they’re asymptomatic or lots of squamous cells, I’m not treating and sending for culture instead. They have to have a pretty convincing UA and symptoms for me to be treating. Nitrite positive is usually hard for me to ignore though, I was taught those only show up when bacteria is present and creating it in urine sitting in the bladder.

Looking forward to people poking holes in the above, please do. This is an area I am sure I need to know more and am always looking to learn.
 
PianoMedic said:
Keflex for most UTIs unless I have a culture that shows cefazolin resistance, it doesn’t penetrate ureter or renal parenchyma as well so 10 days in anybody who isn’t simply dysuria or suprapubic pain. If anything systemic like nausea, fevers, low back or flank pain I’m doing 1 days up to 14 days. I have looked with our pharmacist a few times and seen different dosing frequencies, our local practice is 500 mg BID. I’ve done TID for 10 days for flank pain and UTI (no stone obv) on occasion based on something I saw on UpToDate awhile back but usually I’ll just extend BID to 14 days if they seem reliable. If im at all concerned they may not go that full timeframe, I’ll do cefdinir or cefpodoxime for 7 days. The difference between these two is what my EMR thinks their insurance will cover. My preference is 200 mg bid cefpodoxime, I think this was in idsa for pyelo maybe something about penetrates parenchyma a bit better than cefdinir but I think they both do decently. I rarely use macrobid, creat clearance on my patients sucks too much it seems. Only use Bactrim in skin and soft tissue with recorded mrsa hx or allergy to doxy. Rarely for UTI, almost only in male with concern for prostatitis that has cx with cipro/levofloxacin resistance in the past. If they’re asymptomatic or lots of squamous cells, I’m not treating and sending for culture instead. They have to have a pretty convincing UA and symptoms for me to be treating. Nitrite positive is usually hard for me to ignore though, I was taught those only show up when bacteria is present and creating it in urine sitting in the bladder.

Looking forward to people poking holes in the above, please do. This is an area I am sure I need to know more and am always looking to learn.
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Anyone else like a frisky 5-7 mg/kg of IV gent one time in legit pyelo you are discharging (non pregnant etc)? Or I am the only one?
 
I Try stick with my macrobid if definitly just simple cystitis and straight forward. Otherwise kelfex bid for cystitis, keflex qid for possible pyelo, cefdenir for definite pyelo. Tmp smx or cipro depending on culture data.

For inpatient still prefer ceftriaxone but doing more ancef now, assuming no prior culture data
 
Zebra Hunter said:
Just trimethoprim without the sulfamethoxazole? I don’t think I’ve ever seen trimethoprim by itself, but i know you’re over in New Zealand.
Click to expand...

Yep. Haven't bothered to delve into it, but I suspect someone made a decision most uncomplicated UTIs only need a little bit of help to clear and didn't want to add on the sulfamethoxazole complications/allergies.

Zebra Hunter said:
You’re only giving 5-7 days of keflex for pyelo? The literature is generally pretty scant on antibiotic duration, but almost everyone recommends 10-14 days if using cephalosporins.
Click to expand...

Our pyelonephritis is 1000mg QID cephalexin for 7-10 days.

Dr Mantis Toboggan said:
Anyone else like a frisky 5-7 mg/kg of IV gent one time in legit pyelo you are discharging (non pregnant etc)? Or I am the only one?
Click to expand...

A single dose of intravenous gentamicin is on our protocol as well; I sort of do a "it depends" on how comorbid the patient might be. I tend to feel patients who can go home are well enough they don't need IV gentamicin.
 
xaelia said:
A single dose of intravenous gentamicin is on our protocol as well; I sort of do a "it depends" on how comorbid the patient might be. I tend to feel patients who can go home are well enough they don't need IV gentamicin.
Click to expand...
I like it for sick patients on the fence for hospitalization who won’t stay (your young mom with a temp of 102 and tachycardia/vomiting etc who has to get home cuz there’s no one to watch the kids).

I’ll send them home with something PO too.
 
Zebra Hunter said:
And I don’t really like cephalexin for pyelo due to the QID dosing which can be difficult to get patients to stick to especially when you’re asking them to take it for 10-14 days. I frequently will rx cefpodoxime (3rd generation) for pyelo and complicated UTIs.
Click to expand...
I also use cefpodox 200mg bid for pyelo sometimes but if you want keflex, just do 1g TID instead of 500 qid. That's what I do for both cellulitis and pyelo.
 
Dr Mantis Toboggan said:
Anyone else like a frisky 5-7 mg/kg of IV gent one time in legit pyelo you are discharging (non pregnant etc)? Or I am the only one?
Click to expand...
15 years ago we did this at my old hospital, but I haven't seen this outside of the OB world (chorio,endometriosis) since then.
 
ScepticSkeksis said:
Had a patient from Mexico (legit visiting, not illegal) with Klebsiella only sensitive to Macrobid. His Mexican doctor texted me and recommended this. My first time ever using it!
Click to expand...
Aqui es uno pacient de mi qui tiene uno infectioso de la orina, y Macrobid es el antibiotico seul qui trabaja?
 
Trimethoprim 300mg nocte for 3 days for uncomplicated cystitis in women. Most of Australia, there's 20% resistance in E coli but the risk of treatment failure is actually quite low (we may be biased in ED because the prevalence of severe disease is much higher). The reasoning is it's very safe to start narrow and modify later. It's given specifically at night because it accumulates in the bladder.

Non severe pyelonephritis gets high dose oral Augmentin. If there are any systemic features meriting admission, it's gentamicin 5mg/kg ABW/AdjBW + ampicillin 2g q6hrly (or cephazolin in the Northern Territory due to much higher endemic resistance). Giving ampicillin with gentamicin reduces the risk of C diff, works synergistically, and gentamicin is amazingly bactericidal. Ceftriaxone doesn't cover pseudomonas or enterococci, and it's not my first line choice.

If I'm sending them home, I'm not giving them IV gentamicin unless they really shouldn't be going home. There's a small but real risk of ototoxicity, and I don't really see the benefit if they're tolerating oral antibiotics. I have given single-dose IM gentamicin for cystitis a few times (poor adherence, can't swallow tablets, etc).

Ciprofloxacin is basically verboten in Australia. It's an awful drug and there's often a much better choice.
 
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EctopicFetus said:
Favorite antibiotic for uncomplicated cystitis and Pyelo. Bonus for reason why.
Click to expand...

I routinely mix it up. keeps me on my toes
Cystitis:
- keflex 500 PO BID x5 days
- macrobid 100 Po BID x5 days
- I don't use bactrim or fluoroquinolones all that much

Pyelo:
- keflex 500 PO QID x7-10 days
- bactrim 1 DS PO BID x7-10 days
- vantin (cefpoxodime) 200 PO BID x7-10 days
- I'll use bactrim if they are young.
 
where's my ceftriaxone / cefpodoxime gang at? i use them nearly indiscriminately.
 
Apollyon said:
Aqui es uno pacient de mi qui tiene uno infectioso de la orina, y Macrobid es el antibiotico seul qui trabaja?
Click to expand...
Well they showed me the text from the doctor, and I read Spanish so it wasn't hard to see what he was requesting.
 
ScepticSkeksis said:
Had a patient from Mexico (legit visiting, not illegal) with Klebsiella only sensitive to Macrobid. His Mexican doctor texted me and recommended this. My first time ever using it!
Click to expand...
I do my best to not recommend it- but I am surprised how many times we get the multi-drug resistent klebsiella or pseudomonas where that is really our only oral option.
 
I love Fosfomycin x 1 for women with an uncomplicated UTI. 'Cause I'm lazing and patients are too.

I'm going to have to look into single dose gentamicin. How bad is this drug? Is this a good idea?
 
MechEDoc said:
I love Fosfomycin x 1 for women with an uncomplicated UTI. 'Cause I'm lazing and patients are too.

I'm going to have to look into single dose gentamicin. How bad is this drug? Is this a good idea?
Click to expand...
renal toxicity unlikely in single dose gent with normal GFR, oto and vestibular toxicity is debatable. This author doesn’t think it really happens with a single dose.



I don’t use it for lower uti, rather sicker pyelo in conjunction with PO antibiotics to jump start cure.

www.hopkinsguides.com

Pyelonephritis, Acute, Uncomplicated | Johns Hopkins ABX Guide

Pyelonephritis, Acute, Uncomplicated was found in Johns Hopkins Guides, trusted medicine information.
www.hopkinsguides.com www.hopkinsguides.com
 
MechEDoc said:
I love Fosfomycin x 1 for women with an uncomplicated UTI. 'Cause I'm lazing and patients are too.

I'm going to have to look into single dose gentamicin. How bad is this drug? Is this a good idea?
Click to expand...

It's not unreasonable, even for cystitis. When it seems like the best option, I give it at 3mg/kg ABW/AdjBW.


Goodlet KJ, et al. A systematic review of single-dose aminoglycoside therapy for urinary tract infection: is it time to resurrect an old strategy? Antimicrob Agents Chemother. 2019;63(1):e02165-18.
 
thegenius said:
that's it? No Rx for fosfomycin?
Click to expand...
No rx unless complicated (or male).

Great for homeless and little old ladies.

speaking of random drug stuff. Does anyone still do (or know what happened to) 30 mg/kg acetaminophen loading doses in peds? Also, why don't we give naproxen to kiddos?
 
I wonder how many of the above are even real UTIs. And most should not even be getting a culture. Pretty shocking how willy nilly you guys blast UTIs with pretty broad spectrum antibiotics.
 
uncomplicated UTI- macrobid, keflex

Pyelo (outpatient) Cefpodoxime
 
Rekt said:
I wonder how many of the above are even real UTIs. And most should not even be getting a culture. Pretty shocking how willy nilly you guys blast UTIs with pretty broad spectrum antibiotics.
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I agree with your general point. Asymptomatic bacteruria with contamination present in a UA that was questionably obtained shouldn’t be treated.

However, I think this discussion isn’t about asymptomatic bacteruria. It’s about how to treat clear cut UTIs or pyelo presenting with dysuria and suprapubic pain, or fever and flank pain, with nitrite positive, LCE positive urine with bacteruria and pyuria convincing for infection.

Gentamicin and Fosfomycin seem like overkill to me outside of very specific situations. I also haven’t heard any compelling arguments against using well tolerated, effective Keflex (other than local resistance) or perhaps another generation Cephalosporin in the case of pyelo for outpatient management. Ceftriaxone for admitted patients.
 
thegenius said:
that's it? No Rx for fosfomycin?
Click to expand...
for uncomplicated - just a one time dose. We reserve it for those we know compliance will be an issue and have a legit UTI (homeless, etc) or those with cultures that show no other po options.
Complicated gets 2 or 3 doses q 48-72 hours
 
Assuming I have no recent cultures to guide therapy:

Uncomplicated cystitis:
Macrobid x 5 days, or Cephalexin 500 mg BID x 7 days.

Pyelo:
Cefdinir x 10-14 days

Will be really interested to see new IDSA guidelines on this (which list b-lactams as 2nd line)... pretty much everyone gets a cephalosporin empirically and isn't bouncing back with urosepsis
 
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