Urinary Tract Infection - Complicated Drug Summary

Drug	Dosage	Remarks
First Generation
Cefadroxil	1 g PO 12 hourly	Adverse Reactions Hypersensitivity effects (urticaria, pruritus, rash, anaphylaxis); GI effects (diarrhea, nausea/vomiting, increased LFTs); CNS effects (headache, dizziness, encephalopathy and convulsions associated with high dose); Local effects (phlebitis, pain and/or inflammation); Other effect (candidal infections) Prolonged prothrombin time (PT), prolonged activated partial thromboplastin time (PTT), and/or hypoprothrombinemia (with or without bleeding) have been reported and occurs most frequently with N-methylthiotetrazole (NMTT) side chain-containing cephalosporins Special Instructions May be taken with food to decrease gastric distress Use with caution in patients with non-severe hypersensitivity reactions to cephalosporins, penicillins or other drugs and renal impairment Cefepime/enmetazobactam: If neurotoxicity occurs, discontinue treatment and institute appropriate management
Cefalexin (Cephalexin)	500 mg-1 g PO 6-12 hourly
Cefazolin	1,000 mg IM/IV 8 hourly
Cefradine (Cephradine)	250-500 mg PO 6 hourly or 500-1,000 mg PO 12 hourly
Second Generation
Cefaclor	250-500 mg PO 8 hourly
Cefamandole	0.5-2 g IM/IV 4-8 hourly
Cefoxitin	1-2 g IM/IV 6-8 hourly
Cefuroxime	500 mg PO 12 hourly or 1,500 mg IM/IV 8 hourly
Third Generation
Cefdinir	600 mg PO divided 12-24 hourly
Cefditoren	100-200 mg PO 8 hourly
Cefixime	400 mg/day PO divided 12-24 hourly
Cefoperazone	2-4 g/day IM/IV divided 12 hourly May be increased to 6-12 g/day divided 6-12 hourly for severe infection Max dose: 12 g/day
Cefotaxime	1-2 g IM/IV 8
Cefpodoxime	200-400 mg PO 12 hourly
Ceftazidime	500 mg IM/IV 8-12 hourly
Ceftibuten	400 mg PO 24 hourly
Ceftizoxime	500 mg/day IM/IV divided 6-12 hourly May be increased up to 4 g/day
Ceftriaxone	1-2 g/day IM/IV divided 12-24 hourly Max dose: 4 g/day
Fourth Generation
Cefepime1	500-1,000 mg IM/IV 12 hourly or 2,000 mg IM/IV 12 hourly for severe infection
Cefiderocol	2 g IV 8 hourly
Cefpirome	1-2 g IV 12 hourly
Cephalosporins with Beta-lactamase Inhibitors
Cefepime/enmetazobactam	2.5 g IV 8 hourly x 7-14 days
Cefoperazone/sulbactam	2-4 g/day IM/IV divided 12 hourly
Ceftazidime/avibactam	2.5 g in 100 mL IV infusion over 2 hours 8 hourly x 5-10 days (up to 14 days in patients with bacteremia)
Ceftolozane/tazobactam	1.5 g IV 8 hourly
Ceftriaxone/sulbactam	1.5-3 g/day IM/IV divided 12-24 hourly Max dose: 4 g/day
1Combination with Arginine is available. Please see the latest MIMS for specific formulations and prescribing information.

Drug	Dosage	Remarks
Diaminopyrimidine
Trimethoprim	100-200 mg PO 12 hourly or 200-300 mg PO 24 hourly	Adverse Reactions Dermatologic effects (morbiliform/maculopapular rash, pruritus, photosensitivity); GI effects (nausea/vomiting, epigastric distress, glossitis, abdominal pain); Hematologic effect (anemia); Renal effects (increased blood urea nitrogen/creatinine, hyperkalemia) Special Instructions Use with extreme caution or not at all in patients with hematological disorders especially megaloblastic anemia due to Folic acid deficiency Use with caution in patients with renal impairment or severe hepatic dysfunction and folate deficiency (may consider administration of Folinic acid
Glycopeptide
Vancomycin	500 mg IV 6 hourly or 1 g IV 12 hourly	Adverse Reactions “Red neck syndrome” which is usually related to too rapid infusion: Flushing, erythema, rash over face and upper torso, sometimes hypotension and shock-like symptoms also occur Hypersensitivity effects (anaphylactoid reactions, SJS); Hematologic effects have occurred; Renal effect (nephrotoxicity may occur especially at high doses or in patients with predisposing factors); Ototoxic effects (ototoxicity which is more likely with high plasma concentrations or in renal impairment, may be irreversible; tinnitus may precede hearing loss and can be used as a sign to discontinue treatment) Special Instructions Avoid in patients with renal impairment and glucose-6-phosphate dehydrogenase (G6PD) deficiency Use with caution in patients with impaired hearing or renal function and the elderly Monitor serum concentrations to help avoid renal and otic toxicity Along with CBC and renal function during treatment is suggested to monitor auditory function
Nitrofuran
Nitrofurantoin	50-100 mg PO 6 hourly	Adverse Reactions GI (nausea/vomiting, abdominal pain, diarrhea, anorexia); CNS effects (dizziness, drowsiness, fatigue, headache); Hypersensitivity effects (rash, angioedema, SJS, exfoliative dermatitis, pancreatitis); Respiratory effect (acute pulmonary sensitivity reactions including pulmonary fibrosis); Neuromuscular effects (arthralgia, numbness, paresthesia, weakness); Ophthalmologic effects (amblyopia, nystagmus, optic neuritis) Special Instructions Take with food to decrease GI effects Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake Avoid in patients w/ renal impairment and G6PD deficiency Use with caution in the elderly and in patients with pre-existing pulmonary, hepatic, neurological or allergic disorders and in those with conditions (eg anemia, DM, electrolyte imbalance, debility or vitamin B deficiency) which may predispose to peripheral neuropathy Discontinue if signs of peripheral neuropathy develop
Polymyxin
Polymyxin B	15,000-25,000 units/kg/day IV infusion divided 12 hourly Max dose: 25,000 units/kg/day or 25,000-30,000 units/kg/day IM divided 4-6 hourly	Adverse Reactions CNS effects (dizziness progressing to ataxia, drowsiness, paresthesias); Local effects (pain at IM and thrombophlebitis at IV injection site); Other effects (facial flushing, drug fever, rash, albuminuria, cylindruria, azotemia) Special Instructions Avoid concurrent use of curariform muscle relaxant and other neurotoxic drugs and/or nephrotoxic drugs Use with caution in patients with nephrotoxicity and renal impairment; require baseline renal function and blood levels prior to therapy with frequent monitoring Discontinue if Clostridium difficile-associated diarrhea is suspected or confirmed and paralysis appears
Other Antibacterial
Fosfomycin	3 g PO as single dose or 3 g PO every 48 hours x 3 doses or 6 g IV 8 hourly	Adverse Reactions GI effects (retching, stomach ache); Other effects (hypernatremia and/or hypokalemia, erythematous eruption, injection site phlebitis) Special Instructions Not to be given concomitantly with drugs that inhibit peristalsis Use with caution in patients with cardiac insufficiency, hypertension, hyperaldosteronism, hypernatremia, pulmonary edema, diarrhea during or subsequent treatment, antibacterial agent-associated colitis and pseudomembranous colitis Discontinue if acute, potentially life-threatening hypersensitivity reactions or C difficile occurs

Drug	Dosage	Remarks
Carbapenems
Biapenem	1.2 g/day IV infusion over 30-60 minutes divided 12 hourly	Adverse Reactions GI effects (diarrhea, nausea/vomiting, antibiotic-associated diarrhea/colitis, tongue/tooth discoloration, altered taste); Hypersensitivity effects (rash, anaphylaxis); Other effect (candidal infections) CNS effects (mental disturbances, confusion; Imipenem/cilastatin: Seizures and convulsions have been reported especially in patients with history of CNS lesions or renal dysfunction) Special Instructions Use with caution in patients allergic to penicillins, cephalosporins or other beta-lactams, with renal impairment and CNS disorders (eg epilepsy)
Doripenem	500 mg IV 8 hourly
Ertapenem	1 g IM/IV 24 hourly
Imipenem/cilastatin	500 mg IV 6 hourly or 1 g IV 8 hourly
Meropenem	500-1,000 mg IV infusion over 15-30 minutes 8 hourly
Tebipenem pivoxil	600 mg PO 6 hourly	Adverse Reactions GI effects (diarrhea, headache, nausea, abdominal pain, C difficile infection); Other effects (seizure, increased hepatic enzyme) Special Instructions Contraindicated in patients with hypersensitivity to beta-lactam antibacterials and those with primary or secondary carnitine deficiency or inborn errors of metabolism that may result in clinically significant carnitine deficiency Concomitant use with Valproic acid or Divalproex sodium may reduce the serum concentration of these drugs potentially increasing the risk of breakthrough seizures
Monobactam
Aztreonam	1 g IM/IV 8-12 hourly or 2 g IM/IV 6-12 hourly	Adverse Reactions GI effects (nausea/vomiting, diarrhea, pseudomembranous colitis, GI bleeding); Hepatic effects (jaundice, hepatitis, increased liver enzymes); Other effects (PT and PTT prolongation, local reactions at infusion site, skin rash, pruritus) Special Instructions Use with caution in patients with history of beta-lactam hypersensitivity, renal and hepatic impairment
Aztreonam/avibactam	Loading dose: 2.67 g IV 6 hourly x 5-10 days Maintenance dose: 2 g 6 hourly x 5-10 day	Adverse Reactions Hypersensitivity effects (rash, flushing, bronchospasm, toxic epidermal necrolysis); GI effects (increased liver enzymes, C difficile-associated diarrhea); Other effects (anemia, hypokalemia, pyrexia) Special Instructions Contraindicated in patients with known hypersensitivity to components Concomitant use of organic anion transporter (OAT) 1 and OAT 3 transporter inhibitors (eg Probenecid) is not recommended

Drug	Dosage	Remarks
Na bicarbonate/Na citrate/citric acid/tartaric acid	Urinary alkalinization: Dissolve 4-8 g in cold water then take PO 6-8 hourly Max duration of therapy: 5 days	Adverse Reactions GI effect (mild laxative); Other effects (systemic alkalosis/hypernatremia) Special Instructions Use with caution in patients on low Na diet, with cardiac failure, hypertension, impaired renal function, peripheral and pulmonary edema and preeclampsia Avoid in patients with renal failure or hypernatremia; in conjunction with Hexamine mandelate or Hexamine hippurate therapy; concomitant use of urinary alkalinizers and quinolone antibiotics

Drug	Dosage	Remarks
Aminopenicillins with or without Beta-lactamase Inhibitors
Amoxicillin	500 mg PO 8 hourly or 750-2,000 mg IM/IV 8 hourly or 2,000 mg IM/IV 12 hourly	Adverse Reactions Hypersensitivity effects (rash, urticaria, pruritus, anaphylaxis can occur); GI effects (diarrhea, nausea/vomiting); Other effect (candidal infections) High doses may be associated with CNS effects (encephalopathy, convulsions) Special Instructions Avoid in patients with Penicillin allergy Use with caution in patients with renal impairment
Amoxicillin/clavulanic acid (Amoxicillin/clavulanate, Co-amoxiclav)	625 mg PO 8 hourly or 1,000 mg PO 8-12 hourly
Ampicillin	500 mg IM/IV 4-6 hourly
Ampicillin/sulbactam (Sultamicillin)	1.5-3 g IM/IV 6-8 hourly or 1.5-12 g/day IM/IV divided 6-8 hourly Max dose: 12 g/day IM/IV
Sultamicillin tosylate (Sultamicillin tosilate)	375-750 mg PO 12 hourly
Antipseudomonal Penicillins with Beta-lactamase Inhibitors
Piperacillin/tazobactam	4.5 g IV 8 hourly or 3.375 g IV infusion 6 hourly
Ticarcillin/clavulanic acid (Ticarcillin/clavulanate)	3.1 g IV 4-6 hourly

All dosage recommendations are for non-pregnant and non-breastfeeding women, and non-elderly adults with normal renal and hepatic function unless otherwise stated.  
Not all products are available or approved for above use in all countries. 
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs.   
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information.