UTI Empiric Antibiotics

UTI AntibioticsLast week we discussed making the diagnosis of an urinary tract infection.  Essentially, we reinforced the fact that we can only make a presumptive diagnosis of UTI in the ED.  In some situations, you may prefer to await the urine culture for more definitive answers; however, there will be many occasions when it is deemed appropriate to initiate empiric antibiotics.  When that is the case, what should you choose? Let’s look at some options for Empiric Antibiotics for UTI.

 

UTI: The Bugs

  • Worldwide, over the past several decades, antibiotic resistance has continued to evolve and increase. [Mishra, 2015; Echeverri, 2014; Mirsoleymani, 2014; Edlin, 2013]
  • E. coli is responsible for majority of UTIs (~80%). [Edlin, 2013; Bhat, 2011]
  • Other encountered uropathogens:
    • Klebsiella
    • Proteus
    • Group B Strep – consider in neonates and young infants.
    • Enterococcus – consider in neonates and young infants.
    • Staph saprophyticus
    • Pseudomonas
    • Fungi – seen in immunocompromised or diabetic patients or those with indwelling catheters or on long-term antbiotics.
  • Common contaminants:
    • Cornebacterium species
    • Coag-negative staph
    • Lactobacillus species
    • Alpha-hemolytic strep

 

UTI: Management

  • Local antimicrobial susceptibility patterns are the most important tool to help determine initial therapy. [Edlin, 2013; Jerardi, 2012; Subcommittee AAP, 2011]
  • Duration of therapy:
    • Short course (5 days) is as effective as 7-14 days for uncomplicated cystitis in children
    • Consider short courses for older children.
  • PO vs IV:
    • PO and IV therapies are equally efficacious. [Kowalsky, 2013; Subcommittee AAP, 2011]
    • Children with severe disease (ex, pyelonephritis) or medical complications (ex, immunocompromised) need to be treated with IV therapy until afebrile for 24 hours. Can be converted to oral afterwards.
    • Neonates require full sepsis evaluation and IV antibiotics!
    • >2 month olds:
      • Well appearing >2 month olds have low risk of UTI and concomitant meningitis[Tebruegge, 2011]
      • If considering outpatient management:
        • Kid has to look awesome!
        • Kid has to have excellent access to care.
        • Discuss with Primary Care Provider to ensure that everyone is on the same management page!

 

UTI: The Bugs

  • NO initial empiric choice is perfect.
    • Send the Culture!
    • Ensure follow-up!
  • Cephalosporins [Subcommittee AAP, 2011]
    • Have become a commonly selected 1st choice for UTI. [Bhat, 2011]
    • Some evidence that Nitrite-Negative U/A results may indicate increased risk for resistance to 1st and 2nd generation (Enterocococcus do not convert Nitrate to Nitrite). [Weisz, 2010]
    • Cefaclor
      • 50-100 mg/kg/Day divided in 3 doses
    • Cefixime
      • 8 mg/kg once a day
    • Cephalexin
      • Useful first generation cephalosporin.
      • Will NOT cover enterococcus.
      • 50-100 mg/kg/D divided in four doses.
    • Ceftriaxone
      • IM dosing can be used in those who won’t tolerate oral meds.
      • 50-100 mg/kg every 24 hours.
  • Amoxicillin / Ampicillin [Subcommittee AAP, 2011]
    • A large percentage of E. coli are resistant to ampicillin. [Gaspari, 2006]
    • Does attain high levels in the urine and is effective against E. coli. [Betrosian, 2009]
    • Recommendation is to use Amoxicillin with Clavulanate (20-40 mg/kg/D divded TID).
  • Trimehoprim-Sulfamethoxazole (TMP-SMZ) [Subcommittee AAP, 2011]
    • Ever increasing resistance, plus not an innocuous medicine. [Edlin, 2013]
    • Bacteria that are resistant to ampicillin are commonly also resistant to TMP-SMZ. [Gaspari, 2006]
    • The high resistance makes this a poor choice for empiric therapy of UTI. [Gaspari, 2006]
  • Nitrofurantoin
    • Attains good levels in urine, but not serum.
    • Good for nitrite-negative UTIs. [Weisz, 2010]
    • Should not be used to treat pyelonephritis or febrile infants. [Bhat, 2011; Subcommittee AAP, 2011]
  • Ciprofloxacin
    • Often avoided due to concern for cartilage injury, but this is not supported in the literature.
    • Reserved for resistant organisms. [Bhat, 2011]
    • Can use if need in special cases (ie, cystic fibrosis).

 

The Moral of the Morsel

  • Know your local antibiotic resistance patterns.
  • Avoid using TMP-SMZ empirically for UTI!
  • Ensure the Urine Culture gets sent (it is crucial for the diagnosis and for tailoring therapy).
  • Not every child needs empiric therapy for an abnormal urinalysis. Discuss with the Primary Care Physician when not clearly requiring empiric antibiotics.

 

References

Becknell B1, Schober M, Korbel L, Spencer JD. The diagnosis, evaluation and treatment of acute and recurrent pediatric urinary tract infections. Expert Rev Anti Infect Ther. 2015 Jan;13(1):81-90. PMID: 25421102. [PubMed] [Read by QxMD]

Mishra MP1, Sarangi R2, Padhy RN3. Prevalence of multidrug resistant uropathogenic bacteria in pediatric patients of a tertiary care hospital in eastern India. J Infect Public Health. 2015 Nov 23. PMID: 26617250. [PubMed] [Read by QxMD]

Dev Period Med. 2014 Oct-Dec;18(4):470-6. PMID: 25874786. [PubMed] [Read by QxMD]

Mirsoleymani SR1, Salimi M2, Shareghi Brojeni M3, Ranjbar M3, Mehtarpoor M4. Bacterial pathogens and antimicrobial resistance patterns in pediatric urinary tract infections: a four-year surveillance study (2009-2012). Int J Pediatr. 2014;2014:126142. PMID: 24959183. [PubMed] [Read by QxMD]

Vélez Echeverri C1, Serna-Higuita LM1, Serrano AK2, Ochoa-García C2, Rojas Rosas L2, María Bedoya A3, Suárez M4, Hincapié C4, Henao A4, Ortiz D4, Vanegas JJ1, Zuleta JJ5, Espinal D4. Resistance profile for pathogens causing urinary tract infection in a pediatric population, and antibiotic treatment response at a university hospital, 2010-2011. Colomb Med (Cali). 2014 Mar 30;45(1):39-44. PMID: 24970958. [PubMed] [Read by QxMD]
Mikrobiyol Bul. 2013 Oct;47(4):603-18. PMID: 24237429. [PubMed] [Read by QxMD]

Edlin RS1, Shapiro DJ, Hersh AL, Copp HL. Antibiotic resistance patterns of outpatient pediatric urinary tract infections. J Urol. 2013 Jul;190(1):222-7. PMID: 23369720. [PubMed] [Read by QxMD]

Kowalsky RH1, Shah NB. Update on urinary tract infections in the emergency department. Curr Opin Pediatr. 2013 Jun;25(3):317-22. PMID: 23652682. [PubMed] [Read by QxMD]

Jerardi KE1, Auger KA, Shah SS, Hall M, Hain PD, Myers AL, Williams DJ, Tieder JS. Discordant antibiotic therapy and length of stay in children hospitalized for urinary tract infection. J Hosp Med. 2012 Oct;7(8):622-7. PMID: 22833498. [PubMed] [Read by QxMD]

Tebruegge M1, Pantazidou A, Clifford V, Gonis G, Ritz N, Connell T, Curtis N. The age-related risk of co-existing meningitis in children with urinary tract infection. PLoS One. 2011;6(11):e26576. PMID: 22096488. [PubMed] [Read by QxMD]

Bhat RG1, Katy TA, Place FC. Pediatric urinary tract infections. Emerg Med Clin North Am. 2011 Aug;29(3):637-53. PMID: 21782079. [PubMed] [Read by QxMD]

Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011 Sep;128(3):595-610. PMID: 21873693. [PubMed] [Read by QxMD]

Betrosian AP1, Douzinas EE. Ampicillin-sulbactam: an update on the use of parenteral and oral forms in bacterial infections. Expert Opin Drug Metab Toxicol. 2009 Sep;5(9):1099-112. PMID: 19621991. [PubMed] [Read by QxMD]

Arredondo-García JL1, Soriano-Becerril D2, Solórzano-Santos F3, Arbo-Sosa A4, Coria-Jiménez R1, Arzate-Barbosa P1. Resistance of uropathogenic bacteria to first-line antibiotics in mexico city: A multicenter susceptibility analysis. Curr Ther Res Clin Exp. 2007 Mar;68(2):120-6. PMID: 24678125. [PubMed] [Read by QxMD]

Gaspari RJ1, Dickson E, Karlowsky J, Doern G. Multidrug resistance in pediatric urinary tract infections. Microb Drug Resist. 2006 Summer;12(2):126-9. PMID: 16922629. [PubMed] [Read by QxMD]

Bonsu BK1, Shuler L, Sawicki L, Dorst P, Cohen DM. Susceptibility of recent bacterial isolates to cefdinir and selected antibiotics among children with urinary tract infections. Acad Emerg Med. 2006 Jan;13(1):76-81. PMID: 16365328. [PubMed] [Read by QxMD]

Marcus N1, Ashkenazi S, Yaari A, Samra Z, Livni G. Non-Escherichia coli versus Escherichia coli community-acquired urinary tract infections in children hospitalized in a tertiary center: relative frequency, risk factors, antimicrobial resistance and outcome. Pediatr Infect Dis J. 2005 Jul;24(7):581-5. PMID: 15998996. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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