Empiric Treatment of Urinary Tract Infections – An Opportunity for De-escalation and Avoidance

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A review of the empiric treatment of urinary tract infections with levofloxacin or ciprofloxacin

If you are wondering what de-escalation means, you are not alone.  While this is common practice in hospitals with infectious disease experts and onsite pharmacists, it is not common practice in the long-term care setting, but it should be.  If possible broad spectrum antibiotics such as levofloxacin and ciprofloxacin should be de-escalated to a narrower spectrum antibiotic after the culture and sensitivities (C&S) are back.  This process often happens during an antibiotic timeout.  An antibiotic timeout is just like it sounds.  At 48 hours after the decision is made to start an antibiotic for a possible urinary tract infection (UTI), the C&S is back, and antibiotic treatment should be reviewed.  At this time the antibiotic can be discontinued if the urine test is negative, it can be changed if the organism is resistant to the current treatment, and it should also be changed if the organism is sensitive to a narrower spectrum antibiotic. Continuing broad spectrum antibiotics unnecessarily puts your residents at increased risk for adverse effects, including Clostridium difficile (C.diff.) and the spread of multi-drug resistant organisms (MDROs).  Recent FDA warnings recommending against fluoroquinolone (Levaquin/Cipro) use to treat uncomplicated UTIs further strengthens the argument against utilizing them for initial treatment of UTI.  The International Clinical Practice Guidelines, updated in 2010 by the Infectious Disease Society of America and the European Society for Microbiology and Infectious Diseases, recommends nitrofurantoin (Macrobid) 100 mg twice daily for 5 days, or trimethoprim–sulfamethoxazole (Bactrim) 160/800 mg twice daily for 3 days (if local resistance rates do not exceed 20%) for the initial treatment of UTI in the older adult.  Does your facility have an antibiotic stewardship program to address these and other similar issues?  Your AlixaRx Clinical Pharmacist can provide assistance in the development of an antibiotic stewardship program for your facility to reduce unnecessary antibiotic usage.


References: 1. 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(5):e103–e120.

This article was originally published in our monthly issue of From the Front Lines – a monthly publication that shares best practices and medication-related challenges faced by “front line” staff in long-term care and post-acute (LTCPAC) facilities.

>>> From the Front Lines – October 2016<<<