In this episode, I’ll discuss oral beta-lactams for complicated UTIs.
Most oral beta-lactams (especially cephalosporins)have usually been avoided when treating complicated UTIs out of concern for reduced effectiveness. However, in light of increasing resistance and toxicity issues with fluoroquinolones and trimethoprim/sulfamethoxazole (TMP/SMX), researchers are re-examining oral beta-lactams to see if they were painted with too broad a brush.
A group of researchers published a systematic review in the journal Pharmacotherapy looking at the safety and effectiveness of oral beta-lactmas vs fluroquinolones and TMP/SMX for complicated UTI.
They evaluated 17 studies published within the last 25 years. Overall, oral beta-lactams actually had effectiveness that was comparable to fluroquinolones and TMP/SMX. This held true for complicated UTIs and including bacteremic UTIs.
It was the oral beta-lactams cephalexin, cefpodoxime, cefuroxime, and amoxicillin/clavulanate that had clinical success rates in excess of 90%. Not unsurpisingly, these are the oral beta-lactams with the highest oral bioavailability.
Adverse event rates were much lower than fluoroquinolones or TMP/SMX at 1.3% vs 2.3% and 5.7%, respectively. It isn’t all good news those as oral beta-lactams require more frequent dosing, have variable bioavailability, and may present issues with susceptibility testing.
The authors concluded:
Although not traditionally recognized as first-line therapy, select oral β-lactams demonstrated effectiveness comparable to FQs or TMP/SMX for cUTIs and bacteremic UTI and can serve as effective alternatives in appropriately selected patients. When optimally dosed, these β-lactams achieve comparable outcomes with favorable safety profiles and antimicrobial stewardship advantages. Randomized trials are needed to confirm these observational findings and to better define optimal dosing strategies and shorter treatment durations.
While the evidence might not be as high quality yet as we would like, pharmacists who encounter challenging cases with allergy and resistance patterns that preclude fluroquinolones or TMP/SMX might use this study to support a select group of oral beta-lactams for complicated UTI treatment.
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