How about outpatient treatment? We’ve become good at treating-and-streeting many patients with acute pyelonephritis. However, at the present time, we have no oral antibiotics that are consistently active against ESBLs to treat an upper-tract (pyelonephritis) infection. This is where the superbug headlines have some justification.

If you endeavor to send a patient home and ESBLs are a concern, make sure to culture the urine, get the patient’s phone number, and start out with an ertapenem dose before discharge. Then there’s no perfect choice for oral antibiotics. Combining a beta-lactamase inhibitor drug, amoxicillin-clavulanate, with a third-generation cephalosporin, like cefdinir, may allow the latter to evade beta-lactamase destruction.3 Alternatively, you can go with a fluoroquinolone and hope since these antibiotics, when active, have the best clinical performance. Then be sure to give good discharge instructions and check the culture result in two days when you can contact the patient and make adjustments based on the susceptibilities.

Dr. Talan is professor of medicine in residence (emeritus) at the David Geffen School of Medicine at UCLA and chairman emeritus, department of emergency medicine, and faculty, division of infectious diseases, at Olive View-UCLA Medical Center in Sylmar, California.

References

1. Talan DA, Takhar SS, Krishnadasan A, et al. Fluoroquinolone-resistant and extended-spectrum β-lactamase-producing Escherichia coli infections in patients with pyelonephritis, United States. Emerg Infect Dis. 2016;22(9).
2. 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):e103-120.
3. Prakash V, Lewis JS 2nd, Herrera ML, et al. Oral and parenteral therapeutic options for outpatient urinary infections caused by enterobacteriaceae producing CTX-M extended-spectrum beta-lactamases. Antimicrob Agents Chemother. 2009;53(3):1278-1280.