2012 jul 23 (1395): drugs for urinary tract infections

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Published by The Medical Letter, Inc. • 145 Huguenot Street, New Rochelle, NY 10801 • A Nonprofit Publication Volume 54 (Issue 1395)
July 23, 2012
Drugs for Urinary Tract Infections
Table 2. First-Line Drugs for Acute Uncomplicated
The most recent guidelines from the Infectious Adult Dosage/Duration
Diseases Society of America (IDSA) and its European counterpart on the choice of antimicrobials for treat- ment of uncomplicated urinary tract infections (UTIs) in non-pregnant women focus on the unnecessary use of fluoroquinolones to treat uropathogens that are increasingly becoming resistant to them.1 Resistance of Escherichia coli to ciprofloxacin in the US has increased from 3% in 2000 to 17.1% in 2010.2 ACUTE UNCOMPLICATED PYELONEPHRITIS —
In areas where the prevalence of resistance to fluoro- quinolones such as ciprofloxacin or levofloxacin should quinolones among uropathogens is <10%, a 7-day not be used as first-line agents for empiric treatment of course of ciprofloxacin or 5 days of levofloxacin would uncomplicated cystitis. Before the infecting organism is be a reasonable first choice for empiric outpatient known, the drug of choice for non-pregnant women is treatment of non-pregnant women with acute uncom- trimethoprim/sulfamethoxazole (TMP/SMX) for 3 days, plicated pyelonephritis. TMP/SMX for 14 days is an as long as the local rate of resistance to TMP/SMX alternative for treatment of susceptible uropathogens.
among urinary pathogens is <20%. An equally effec- Another alternative is a single IV dose of a long-act-ing parenteral third-generation cephalosporin, such Table 1. First-Line Drugs for Acute Uncomplicated
as 1 g of ceftriaxone (Rocephin, and others), followedby 10-14 days of an oral cephalosporin to which the Adult Dosage/Duration
pathogen is susceptible. Oral beta-lactam agents are generally considered less effective for treatment of pyelonephritis than fluoroquinolones or TMP/SMX.
The recent IDSA Guidelines did not include any rec- ommendations for treatment of complicated UTIs.
Urinary tract infections that recur after treatment, are tive alternative with a low rate of resistance among E.
associated with indwelling urinary catheters, urologic coli is nitrofurantoin for 5 days.3 A single dose of fos- surgery or obstructive uropathy, or are acquired in fomycin, which has a broad spectrum of activity hospitals or nursing homes are more likely to be due against the usual uropathogens, is another to antibiotic-resistant gram-negative bacilli, entero- alternative.4,5 Beta-lactams such as amoxicillin/clavu- lanate (Augmentin, and others), cefdinir (Omnicef, andothers), cefpodoxime (Vantin, and others) or ceftibuten An oral fluoroquinolone, such as ciprofloxacin or lev- (Cedax) could also be considered, but are less likely to ofloxacin, can be useful in treating such infections in outpatients. Oral amoxicillin/clavulanate, an oral FORWARDING OR COPYING IS A VIOLATION OF U.S. AND INTERNATIONAL COPYRIGHT LAWS
Fosfomycin for urinary tract infections. Med Lett Drugs Ther Table 3. Some Adverse Effects*
ME Falagas et al. Fosfomycin versus other antibiotics for the Adverse Effects
treatment of cystitis: a meta-analysis of randomized controlled trials. J Antimicrob Chemother 2010; 65:1862 TM Hooton. Uncomplicated urinary tract infection. N Engl J (rash, urticaria, photosensitivity,fever), hemolysis in G6PD deficiency, Drugs for bacterial infections. Treat Guidel Med Lett 2010; 8:43.
allergic reactions (includingpulmonary infiltrates), lupus- EDITOR IN CHIEF: Mark Abramowicz, M.D.
EXECUTIVE EDITOR: Gianna Zuccotti, M.D., M.P.H., F.A.C.P., Harvard Medical
EDITOR: Jean-Marie Pflomm, Pharm.D.
Corinne E. Zanone, Pharm.D.
CONSULTING EDITORS: Brinda M. Shah, Pharm.D., F. Peter Swanson, M.D.
Fosfomycin tromethamine Diarrhea, nausea, headache, CONTRIBUTING EDITORS:
Carl W. Bazil, M.D., Ph.D., Columbia University College of Physicians and Surgeons
Vanessa K. Dalton, M.D., M.P.H., University of Michigan Medical School
Eric J. Epstein, M.D., Albert Einstein College of Medicine
Jules Hirsch, M.D., Rockefeller University
David N. Juurlink, BPhm, M.D., Ph.D., Sunnybrook Health Sciences Centre
Richard B. Kim, M.D., University of Western Ontario
Hans Meinertz, M.D., University Hospital, Copenhagen
Sandip K. Mukherjee, M.D., F.A.C.C., Yale School of Medicine
Dan M. Roden, M.D., Vanderbilt University School of Medicine
F. Estelle R. Simons, M.D., University of Manitoba
Jordan W. Smoller, M.D., Sc.D., Harvard Medical School
Neal H. Steigbigel, M.D., New York University School of Medicine
Arthur M. F. Yee, M.D., Ph.D., F.A.C.R., Weil Medical College of Cornell University
drowsiness, insomnia, photo-sensitivity reactions, QTc SENIOR ASSOCIATE EDITORS: Donna Goodstein, Amy Faucard
ASSOCIATE EDITOR: Cynthia Macapagal Covey
EDITORIAL FELLOW: Esperance A.K. Schaefer, M.D., M.P.H., Harvard Medical
*For brief (<14 days) treatment of uncomplicated UTIs, all of these agents MANAGING EDITOR: Susie Wong

third-generation cephalosporin such as cefdinir or PRODUCTION COORDINATOR: Cheryl Brown
ceftibuten, or oral TMP/SMX can be used if the infect- EXECUTIVE DIRECTOR OF SALES: Gene Carbona
ing organism is found to be susceptible.

In hospitalized patients with complicated UTIs, parenteral treatment with cefepime (Maxipime), a third generation Arthur Kallet and Harold Aaron, M.D.
cephalosporin such as ceftriaxone, a fluoroquinolone, Copyright and Disclaimer: The Medical Letter is an independent nonprofit organization
that provides health care professionals with unbiased drug prescribing recommendations.
ticarcillin/clavulanate (Timentin), piperacillin/tazobactam The editorial process used for its publications relies on a review of published and unpub-lished literature, with an emphasis on controlled clinical trials, and on the opinions of its (Zosyn, and others), or a carbapenem is generally recom- consultants. The Medical Letter is supported solely by subscription fees and accepts noadvertising, grants or donations. No part of the material may be reproduced or transmit- ted by any process in whole or in part without prior permission in writing. The editors donot warrant that all the material in this publication is accurate and complete in every CONCLUSION — Fluoroquinolones should not be
respect. The editors shall not be held responsible for any damage resulting from any error,inaccuracy or omission.
used empirically for treatment of acute uncompli- Subscription Services
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should be used instead. Use of a fluoroquinolone is 3 years - $279. $49.00 per year forstudents, interns, residents and still recommended for empiric treatment of acute Customer Service:
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complicated urinary tract infections.  Fax: 914-632-1733Web Site: www.medicalletter.org K Gupta et al. International clinical practice guidelines for the Special fees for bulk subscriptions.
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.
GV Sanchez et al. In vitro antimicrobial resistance of urinaryEscherichia coli isolates among U.S. outpatients from 2000 to2010. Antimicrob Agents Chemother 2012; 56:2181.
K Gupta et al. Short-course nitrofurantoin for the treatment ofacute uncomplicated cystitis in women. Arch Intern Med 2007;167:2207.
The Medical Letter • Volume 54 • Issue 1395 • July 23, 2012

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