Management of Urinary Tract Infections in Patients with ESBL-Producing Organisms

Introduction to ESBL Infections

• The American Thoracic Society recommends that patients with a history of ESBL-producing organisms should have a repeat urine culture ordered, as ESBL organisms frequently demonstrate resistance to fluoroquinolones, making empiric coverage potentially inadequate 1, 2.

Key Clinical Rationale

• ESBL-producing Enterobacteriaceae frequently carry co-resistance to fluoroquinolones, making levofloxacin potentially ineffective even at therapeutic doses for pneumonia 1, 2.
• The Infectious Diseases Society of America recommends that nocturia alone does not constitute symptomatic UTI in the absence of dysuria, urgency, suprapubic pain, or systemic signs of infection 3, 4.
• Obtaining a urine culture is appropriate to determine if bacteriuria is present and whether it represents asymptomatic bacteriuria (ASB) or true infection 4, 5.

Treatment of ESBL Infections

• The European Association of Urology recommends that asymptomatic bacteriuria should not be treated in non-pregnant adults, even with ESBL organisms present, as treatment does not reduce subsequent UTI risk and increases antimicrobial resistance and adverse effects 3, 5, 6.
• The American College of Clinical Pharmacy recommends that carbapenems (ertapenem, meropenem, or imipenem) are first-line therapy for ESBL infections 1, 7, 8.
• The Infectious Diseases Society of America recommends that cephalosporins and fluoroquinolones should be avoided for ESBL infections despite possible in vitro susceptibility, as clinical outcomes are poor 1, 2, 8.

Practical Management

• The Clinical Infectious Diseases society recommends that urine culture should be ordered now given history of ESBL and new urinary symptoms, and empiric UTI treatment should not be initiated if the patient has only nocturia without dysuria, urgency, fever, or suprapubic pain 3, 4.
• The American Journal of Respiratory and Critical Care Medicine recommends that levofloxacin for pneumonia should be continued as indicated, but it will not reliably cover ESBL organisms if UTI develops 1, 2.
• If culture grows ESBL organisms, treatment should be guided by symptoms, with carbapenem or susceptibility-guided oral agent used for localizing UTI symptoms, and ceftazidime-avibactam or meropenem-vaborbactam for bacteremia/sepsis 8, 9.