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Difficulty: EasyInfectious Diseases

A 52-year-old man was admitted to the hospital 3 days ago for acute pyelonephritis. At the time of admission, he presented with a temperature of 39.1∘C39.1^\circ\text{C} (102.4∘F102.4^\circ\text{F}), left-sided costovertebral angle tenderness, and leukocytosis. He was empirically started on intravenous piperacillin-tazobactam. Currently, he has been afebrile for 24 hours, his flank pain has largely resolved, and he is eating a regular diet without nausea. The urine culture obtained on admission has grown >100,000 CFU/mL>100,000\text{ CFU/mL} of *Escherichia coli*. Antimicrobial susceptibility testing indicates the isolate is susceptible to trimethoprim-sulfamethoxazole, levofloxacin, ceftriaxone, and piperacillin-tazobactam. Which of the following is the most appropriate next step in the management of this patient's infection?

  1. Transition to oral trimethoprim-sulfamethoxazoleAnswer
  2. B
    Continue intravenous piperacillin-tazobactam
  3. C
    Switch to intravenous ceftriaxone
  4. D
    Transition to oral linezolid
  5. E
    Transition to oral fosfomycin

Answer

Transition to oral trimethoprim-sulfamethoxazole
The patient has acute pyelonephritis and has shown significant clinical improvement on empiric intravenous antibiotics. He is now afebrile, stable, and tolerating oral intake, which are the classic criteria for stepping down from intravenous to oral therapy. When transitioning to oral therapy, a targeted, narrow-spectrum agent should be chosen based on culture and susceptibility results. Transitioning to oral trimethoprim-sulfamethoxazole is the most appropriate next step because it achieves high concentrations in the renal parenchyma, the isolate is susceptible, and it avoids the collateral damage associated with excessively broad-spectrum agents.

Step-by-Step Solution

1
Evaluate the patient's clinical stability and readiness for oral intake.
The patient is afebrile, hemodynamically stable, and tolerating a regular diet.
These are the established criteria for transitioning a patient from intravenous to oral antibiotic therapy.
2
Review culture and susceptibility data to select an appropriate agent.
The infection is caused by E. coli susceptible to trimethoprim-sulfamethoxazole.
Step-down therapy should utilize the narrowest-spectrum effective oral agent to promote antibiotic stewardship and avoid collateral damage.

Key Concept

Criteria for IV to PO antibiotic transition and stewardship in pyelonephritis
Estimated Time:1m 0s
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Topics

Infectious Diseases

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