Bedside Clinical Question
· What are preferred oral antibiotics for the treatment of uncomplicated cystitis caused by ESBL-E?
Background
· The rise in antimicrobial resistance continues to be a global crisis and the CDC has designated ESBL-E pathogens as urgent or serious threats.
· Extended Spectrum Beta-Lactam producing Enterobacterales (ESBL-E) produce enzymes that break down commonly used penicillin and cephalosporin antibiotics.
· With a limit on the number of hospital beds and patient’s desire for discharge, having an oral outpatient treatment option can be useful.
Answer
· Nitrofurantoin 100 mg twice daily for 5 days, or sulfamethoxazole/trimethoprim 800mg/160mg (Bactrim DS) 1 tablet twice daily for 3 days are the preferred outpatient treatment options for uncomplicated cystitis caused by ESBL-E.
· If CrCl <60 mL/min, avoid the use of nitrofurantoin due to increased risk of peripheral neuropathy and inadequate drug levels.
· If CrCl <30 mL/min, recommend sulfamethoxazole/trimethoprim 800mg/160mg (Bactrim DS) 1 tablet ONCE daily for 3 days.
· In a head-to-head trial of treatment of acute uncomplicated cystitis in women, clinical cure was achieved in 79% of the Bactrim group and in 84% of the nitrofurantoin group.
· The most common adverse effects of these medications include GI upset and allergic skin reactions.
Conclusion
· When appropriate, the preferred outpatient oral treatment for ESBL-E uncomplicated cystitis is Nitrofurantoin or Bactrim.
Written by: Travis Hanson, P4 Pharmacy Student, UIC Doctor Pharmacy Candidate
Reviewed by: Joanne C Routsolias, PharmD, RN, BCPS
References
Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious Diseases Society of America Guidance on the Treatment of Extended-Spectrum β-lactamase Producing Enterobacterales (ESBL-E), Carbapenem-Resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with Difficult-to-Treat Resistance (DTR-P. aeruginosa). Clin Infect Dis. 2021;72(7):e169-e183. doi:10.1093/cid/ciaa1478
Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52:e103–20.
Gupta K, Hooton TM, Roberts PL, Stamm WE. Short-course nitrofurantoin for the treatment of acute uncomplicated cystitis in women. Arch Intern Med. 2007;167(20):2207-2212. doi:10.1001/archinte.167.20.2207